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HomeMy WebLinkAbout0122 PARK AVENUE 3r h to �" ..e •;•, a}t .. ". ^`» _.{.�'.'.. .5.:'.r:, ;. _i.: a., v:� 4} ,e ,d, �N,- ..r•. �,. '^ ^''.r .t d 1Y. Ft".°_,}n,% .;: �.�,c,:i c -.d."a.., ..„ s•iA to 0 u , fi u "14 .� co r � G a A � � z KV J , at S a , 4 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION �� o CQb Ito Map Parcel Application # Health Division Date Issuedd C Conservation Division Application Fe Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation /Hyannis _ �k yl'Z�II L Project Street Address a V e Village C ely) e r 41 I e Owner M ►,n dt Address Jq-y-n e Telephone .j t,, 1 Permit Request 1 � c7 La I PVV r 7 v4c U-n i t5 _Fox 1 ) QC7 C1'11 C�S� Coo' li- 4 © C i'.'v\ 0he` a&bye a-rNa i-Y\ 1'"Ke 5e'Ief, Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation U O IS a�onstruction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. � 7- Dwelling Type: Single Family 9i/ Two Family ❑ Multi-Family (# units) -- 1 Age of Existing Structure Historic House: ❑Yes ❑ No On Old Kings Highway:..W Yes-'❑ No vi Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other -- r Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) 6 Number of Baths: Full: existing new Half: existing new_ ,=- a s ' at Number of Bedrooms: existing —new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) NameBIC( 8YO(9 , R' �C�� Telephone Number C77 yJ V? — Q® r.�' f Address ALtVY\ Cf4 R J License #�'I l 7 t 7 MF Mi 115 / " l A �'6 Y0 Home Improvement Contractor# Worker's Compensation # A/Ca,-3 1 5"3710 H�� ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO 9VYV\i9 SIGNATURE DATE +� FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. F: ADDRESS VILLAGE OWNER DATE OF INSPECTION: '• FOUNDATION FRAME INSULATION i= 'r FIREPLACE ELECTRICAL: ROUGH FINAL 4 i 3 .` PLUMBING: ROUGH FINAL GAS: ROUGH FINAL !.c FINAL BUILDING r. DATE CLOSED'OUT ASSOCIATION PLAN NO. iY ,S ' �r `The Commonwealtli of Massachusetts Department of Industrial Accidents rl Office of Investigations ll`4` 600 Washington Street` Boston, MA 02111, \ U r f"= www.mass.gov/dia Workers' Compensation Insui ance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly r 6 , Name (Business/Organization/Individual): B.� ro�^ P) 1 1 Address: g, M 0 V-A G vJai4 I `� City/State/Zip: . M .1 115 AA A 0ai �4�Phone Are you an employer? Check the appropriate box: Type ofproject(required):. I..FZI am a py em to er with Ll . 4. Elm I a a general contractor and'I 6..❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or parfier- listed on the attache 1.d sheet. t ?. ❑Remodeling ship and have no employees These sub-contractors have 8. .❑Demolition Y working for me in any capacity workers' comp. insurance. 9. ❑ Building addition [No workers'comp. insurance 5. ❑ We are a corporation an&its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ i am a homeowner doing all work right of exemption per MGL l I.XPlumbing repairs or additions myself. [No workers' comp. W. _ c. 152, §I(4), and we have no 12.❑ Roof repairs insuram(Frequired.]t employees. [No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box#] must also fill out the section below showing t}ieir workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the.sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information Insurance Company Name:: L.1 e r Mutudl Policy#or Self-ins. Lia #: Ca' -5'` 37�% �°�� �� Expiration Date: J/ Job Site Address: I 'I'Q Y k 119 V e C e-.Y1 QJ VI /a'f City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage:as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year-imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded.to the Office of Investigations of the DIA for insurance-coverage verification. ` I do hereby certify unde airs and penalties of perjury that the.information provided abov ' true and correct Dater 3/'I Si ature: .~7 Phone Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/L,icense# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other Contact Person: Phone#: DATE CERTIFICATE OF LIABILITY INSURANCE 102/28/2011 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 Schlegel s Schlegel Insurance Brokers Inc NAME. PHONE FA (A/C,No,Ext): 34 MAIN STREET E-MAIL ADDRESS: - PRODUCER — -- — - -- --...--------_..... .-- --.... CUSTOMER ID#: - West Yarmouth, MA 02673 INSURER(S)AFFORDING COVERAGE j NAIL# INSURED INSURERANGM INSURANCE Alex Braga Dba Braga Bros Plumbing & Heating INSURER B PROGRESSIVE 2 MountWood Rd _ INSURERC: - INSURER D: - Marstons Mills, MA 02648 INSURERS: 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 LTR TYPE OF INSURANCE INSR WVO POLICY NUMBER OLICY EF POLIC P .(MM/DDIYYYY) (MMIDDM'VY) LIMITS A GENERAL LIABILITY MP03439T 02/17/11 02/17/12 EACH OCCURRENCE $1,000,000 ._----}( COMMERCIAL GENERAL LIABILITY - - PREMISES AMAGETO"RENTED_(Ea occurrence) $500,000 CLAIMS-MADE C OCCUR MED EXP(Any one person) $10,000 PERSONAL&ADV INJURY $1,00 0,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $2,OOO,OOO POLICY PE LOC $ B AUTOMOBILE LIABILITY 04574174 02/24/11 02/24/12 COMBINED SINGLE LIMIT ANY AUTO _ (Ea accident) $ -ALL OWNED AUTOS BODILY INJURY(Per person) $ 100,000 }{ SCHEDULED AUTOS BODILY INJURY(Per accident) $ 300,000 HIRED AUTOS PROPERTYDAMAGE $ 10O 000 • (Per accident) r NON-OWNED AUTOS $ ' r L $ UMBRELLA LIAB OCCUR EACH OCCURRENCE _ $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ I DEDUCTIBLE $ RETENTION $ $ WORKERS DENIPL YERS*LIAILITTION WC2-31S-376462-010 03/04/10 03/04/11 X We U.'T oTH- � AND EMPLOYERS'LIABILITY V/N TORY LIMITS ER ' ANVPROPRIETOR/PARTNDED? CUTIVE 03/04/11 03/04/12 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 r DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more space is required) THE WORKERS COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR ALEX BRAGA CERTIFICATE HOLDER CANCELLATION ' TOWN OF BARNSTABLE BUILDING DIVISION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 MAIN STREET ACCORDANCE WITH THE POLICY PROVISIONS. HYANNIS, MA 02601 FAX # 508-790-6230 AUTHORIZED REPRESENTATN ATTN: PL ING DEPARTMENT ©1988-2009 ACOR ORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD z C®MMONVVEALTH -F MASSACtiUSETTS 0, 0 v a IN PLUMBERS AND GASFITTERS � .. t LICENIS�FrDT&SAA#&i ITvsLUMBER CD m ALEX B BRAGA 4t:' o a 2 MOUNTWOOD RDCD 00 . O'd3 M MARSTONS MIL'LS . MA 02648-2111 CD m.o a*� m 7Dr-- ------ - ------------------------- '" w -! COMMONWEALTH OF MASSACHUSETTS co I R. . B R A D fT LICENSED AS A JOURNEYMAN PLUMBER F c` M ISSUES THIS.LICENSE TO }..'w -o 1 m ro o o ALEX B BRAGA 2 MOUNTW00D, RD e Too MARSTONS MILLS MA 02C48-2111 31'524 05/01/12 757564f o o A C a Er 3 r COMMONWEALTH OF.MASSACHUSETTS _- AS A MASTER-UNRESTRICTED ISSUES THE ABOVE LICENSE TO: ALEX. B BRAGA o Q - o' 2 MOUMTWO'OD RD N ... MARSTONS MILLS MA 02648-2111R 6717 08/28/12 977,645- o N bas e. The System,is theSoluttoh" a The following person has successfully completed the Gastite certification Training Program and ishereey recognized asa The person named below has completed the TracPipe training program and,is hereby awarded the Qualified Gast?te Installer. ' CERTIFICATE F O TRAINING. # Alex Van Nor Braga-- Bill man Instruct" — A I e x E }01 6raga BY05. 1 � B aga Br°s Pg&-Htg 10/07/2009 Installer's Name Company Company - 08G4386,0 Date - Ce'ficate\D 169525 UCerficcate Authorized to pucsC sti;e.-lex;bie Gas?i ',_800662-02"v6 . 91339683 I ao 3 "v.G s,ice.°o�, No. Year Month Day 9i. 4oprHergyti Town of Barnstable Regulatory Services &ILWSTrABLE, ' MASS. $ Thomas F. Geiler,Director m qo s639• Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 ; www.town.barnstable.M2.US Office: 508-862-4038 Fax: 508-790-62: Property Owner Must . Complete and Sign This Section - If.Using A Builder as Owner of the subject ro`e P P ?rtY here by authorize �} �Q Q Ivy kil-,004 ` to act on my behalf, m all matters relative to work authorized by this building permit application for. (Address of ob) a . K/14A41--C, 40 Y Signature of 00. Date � ia1OT Print Name Ifproper Owner is applying forpermitplease complete the Homeowners License Exemption Form on the reverse side. ;Q:F0RMS:0 WNERPERMISS10N �of tHE ray. Town of Barnstable Regulatory Services Yf BaRrrsrAaLE, Thomas F. Geiler,.Director, . MAss Building Division plFDY A Tom Perry,Building Commissioner - 200 Main Street; Hyannis,MA 02601 ww-w.town.barnstable.ma.us Office: 508-862-4038 Fax: 509-790-6230 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 dwellinZS 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 Persoa(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 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"ceitifies 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 EXEhf?TION 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 homco Amrr 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 supcn-isor(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 weith 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 caret amend and adopt such a fom✓certification for use in your community. A Home Energy Raters LLC BTorrey @EnergyCodeHelp.com Box 989,E.Sandwich,Ma 02537 - 888-503-2233 Duct Leakage Test = Address: 122 Park Ave Centerville, Ma 02632 Date —'June 1, 2011 Test Type — Post Construction - Total Leakage to outside. - Conditioned floor area =3366 Sq FT. To comply with Section 403.2.2 Of the 2009 IECC Code in-this home the Maximum duct leakage CFM = 269.28 CFM (3366 /100 x 8 = 269.28), Duct leakage tested = 165 CFM Post Construction Test — Combined Duct Blaster and Blower door This Home complies with Section 403.2.2 Of the 2009 IECC Code 0%j e; of Test; 1 June 2011 Teohniolan: C:NtaRgo a Test mile; Untitled - Customer; Draga Orothem Building Address: 122 Park ire .b f 122 Puk AIW@2 l`,la 0202 ente rllle,b +0203 Phone: Pax: Togk ResultsA 1, t,,,asumd Cunt Wok p; ; . CFM 112's Iri,(+t. 0,0 ,E 7, Duct UokFige as a Peroent of Systen Arflow; 3, Cuot Leakage as a Percent of wilding Floor ken; . 1,9% ' 4. 1,eakage Split: upph-o Side; return Side: 6, Du+ortt W-nkage Cume; Plow Coefflol int (C); 9. •_ �ponent fin); �.�40 ip��u��e�i� . - - ' _ 4 Teat lest Mode, Pressuria lon Tet Pre�surn; 25.0 Pa -153uipmew series 8 mi nn eapol l s Cuok Bl aster Test Try p 0;,: Outside Leakage � (Cor-bine€f Quo'tllagtex t -- and Blower Door Test� L O BuIld.ing and 8yste n, Nira-rneters: rigor,` : sA• #, fe s Supply C e tin9 Pr5sur . pa- OMI -� 01WHOW: o. Avem9a Favor Cper-r ing Pressure; rya� � L .; c Contact our office with any questions, _. Bruce Torrey, • 6.,., . � ,. - �• , ;, 1 Certified HERS Rater Home Energy Raters LLC TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application # Health Division Date Issued Co( n Conservation Division Application Fee Planning Dept. :-,Permit Fee' Date Definitive Plan Approved by Planning Board f/`/10. Historic OKH _ Preservation/ Hyannis V Project Street Address Village C17V Owner (t- Address Telephone Permit Request lalwz C w, I U�r f u AV Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay � 1 Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family°.❑ Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑Gas ❑ Oil ❑ Electric ❑Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: 0 Yes ❑ No Detached garage: ❑ existing 0 new size—Pool: ❑ existing ❑ new size _ Barn: ❑.existing LJ-hew =size_ Atttthed garage: ❑existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: _ `�7 �E c a Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ M Commercial ❑Yes ❑ No If yes, site plan review# co Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) ((�� Name � ' K�ny Telephone Numb " Address P66 License # Home Improvement Contractor# Worker's Compensation # P� ��� ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO— SIGNATURE DATE © � �G t � c ' FOR OFFICIAL USE ONLY APPLICATION# r .DATE ISSUED : MAP/_PARCEL NO.. { ADDRESS VILLAGE OWNER DATE OF INSPECTION: f l": FOUNDATION,. FRAME Y INSULATION_ t ' . FIREPLACE ELECTRICAL: ROUGH FINAL !f PLUMBING: ROUGH FINAL t T GAS i ROUGH , ;•r f ; FINAL i , {, > __,DATE.CLOSED-OJUT ,. i . ASSOCIATION PLAN NO. rr r The Commonwealth of Massachusetts Deparinlent oflhdustrialAccide72ts Office of Investigations '600 Washington Street Boston, MA 02111 yy www.rnass.gov/dia Workers' Comp ensation'Insur,ance Affidavit: Builders/Contractors/F+j6ctricians/Plumbers Applicant Information r Please Print Legibly Name (Business/Organization/Individual): Address: II ^ct City/State/Zip: �� Phone Are ou an employer?•Check the appropriate box": r Type 0fproject(required): 4. I am a general contractor art VI 1. I am a employer with� ❑ 6. ❑ New construction * have'hired the sub-contractors.. • eiriployees(full and/or paYt-tune) . - ­'.liste on d the attached sheet. 7., ❑ Remodeling m 2.❑ I a a sole proprietor-or partner- �, ship and have no employees These sub-contractors lave g ❑'Demolition workingfor me in any.ca act employees and'have workers' capacity. 9. ❑ Building addition [No workers' comp. insurance COMP.insurance.f r ' 5. We. are a�corporation and its 10.❑ Electrical repairs:or additions required.] ❑.. officers have exercised their 11.❑ PlLmbing repairs or additions 3.❑ 1 am a homeowner doing all work• - _ � t- , myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.] c. 152 §1(4), and we have no x ;employees [Nuworkei"s 1.3.❑ Otber comp.insurance required.] *Any applicant that checks box 91 must also fill'out thescction below showing thci�workcrs,';romprnsation policy,inforrnation. t Homeowners who submit this affidavit indicating they arc doing all work and ihen.hire outside contractors must submil a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name'of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have cmployecs,lhcy rnust provide their workers'comp.,policy number. I am an employer that is providing workers'compensatioriinsurance for my employees. Below`is Ihepolicy and job site information Insurance Company Name: Policy# or Self-ins.Lic. # �/d}—�1 1�1� e�( Expiration'Date: Job.Site Address: 1 Z , t .f' .. City./State/Zip: 4ZMt tdV Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Scction',25A of MCI,c, 152�cantlead.to.the imposition of criminal,penalties of a fine up to $1,500.00 and/or one-year iinprisoni lent 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. B.e advised that a copy of this statement may be forwarded to the Offiee-of Investigations of the DIA for insurance coverage verification: I do hereby certify tinder the ains and penalties ofperjury that the information provided above is trzte and correct. f Si aturc: wBat— Phone#: Official use only. Do nor write in this,area, to be completed by city or town official City or Town: Permit/License4# Issuing Authority (circle one): 1. Board of Health 2. Building Department 3, City/Town Clerk 4. Electrical Inspector 5, Plumbing Inspector_ 6. Other Y, Contact Person: Phone#: hformation and hStructzons Massachusetts CcneraJ l vs chapter 152 requires all employers to provide workers' compensation for their employees, Pursuant to this sLatule/an employee is defined as "...every person in the rvice of another under any contract of hire, , express or implied, rat or written." An emplDyer is deft ed as "an individual, partnership, association, co oralion or other legal entity, or any tw Or Lbr, e of the foregoing enga ed in ajoin(enterprise, and including the lega epresentaLives of a deceased employer, receiver or Lrustee of a individual partnership, association or other egal entity, employing employees. However the owner of a dwelling hou e having not more than three apartments d who resides therein, or the occupant of the dwelling house of anothe ho employs persons to do maintenan , constriction or repair work on such dwelling house or on Lhe grounds or build* appurtenaot thereto shall not becau e of such employmeril be deemed to be an employer." MGL chapter 152, §25C(6) also tatts that "every state or Joc licensing agency shall withhold the issuance or renews) of a license or permit to perate a business or to co struct buildings in the commonwealth for any applicant who has not produced a eptable evidence of co pliance with the insurance coverage required." Additionally,MGL chapter 152, §25 7) states "Neither the onunonwealth nor any of its political subdivisions shall eniei into any contract for theperforrn e of public.-Work a it acceptable evidence of compliance with the insurance requirements of this chapter have beenpr ented to the con acting authority." Applicants Please fill out.the workers' compensation affi vit co letely, by checking the boxes that-'apply to your situation and, if of necessary,supply sub-contraetor(s) name(s), ad ess(e and phone number(s)along wish their cerlificaie(s)other than the insurance, Limited Liability Companies (LLC)or Led Liability Partnerships(LLP)with no employees o members or partners, are not required to carry work compensation insurance. if an LLC or LLP does have employees, a policy is required. Be advised that this ffidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage, 1 o be sure to sign and date the affidavit, The affidavit should be returned 10 the city or lows thai•the application r th permit or license is.being requested,not the Department of rk s' dustrial Accidents. Should you have any questi s rega ing the law or if you are required to obtain a,woer In compensation policy,please call the Department the num cr listed beloy,�,,Self-insured companies should enter their self-insurance license number on the appropriate inc. City or Town Officials Please be sure that the affidavit is complete an printed legibly; , e Department has provided a space al the bottom of the affidavit for you to fill out in the event e Office of]nYestig lions has to contact you regarding the applicant. Please be sure Lo fill in the permit/license nu her which will be use s a.reference number. Ln addition,an applicant that must submit multiple permivllicense app icaLions in any given yea need only subrnil one affidavit indicating current policy information(if necessary)abd under Job Site Address" the appl ant should write"all ]orations in _(city or town)."'A copy of the affidavit that has bee off cially stamped or rnarke by the city or town may be provid ed to the applicant as proof that a valid affidavit is o file for future permits or]teen s. Anew affidavilJnust be filled riot each year. Where a home owner or citizen is obt fining a license or permit not rela d to any businessor commerci a] venture (i,e. a dog license or permit to burn leaves c.) said person is NOT required to omplete this aftdavil. The Office of Invesligat�ons woo i e o ��� -�� d shoU➢d ouhave any questions, please do not hesitate to give us a call. The Department's address,telephone and fa number: The omrnonwealth of Massachusetts De rtmcnt of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111. Tel. # 617-727-4900 ext 406'or 1-877-MASSAFE Fax 9 617-727-i7749 Revised 4-24-D2 www.mass.gov/dia Rue 04 2010 1 :43PM ERSYSEE FRX 5087659151 p. 1 Rug• 04 10 02:30p p, 1 Town of Barnstable'be Regulatory Services May Thomas F.Geller,Director Building Division rOm Yvt7,Building Canmossione r 200 Main Street;Ifr=gi.MA 02601 www-town,barartabie.ma.us Office: 5 08-8624Q3 8 Fax: 508-790-6230 Property Owner Must Complete and Sign.This Section I Us' ABuilder as 0W=of the:ubjectvwperty hereby authorize - V'a Vx dq-d to act on n7 behalf, is al=TMM reLvive to Vork autholized by this balding pemit apphmdm for. Czyder !�k (Addtz53 ofJ ) Lsigaz MWW o e Dzue tGh,��� Pont Naime If L pext—C�neris:applying forpemait please complete_the Horneowners License Exemption Porm-on the reverse side. QTORMS-OWNExPERMIcs,otj IQ/28/09 12 : 46 : 519 PM 4170 ® 04/04 ACORD. CERTIFICATE OF INSURANCE ' DATE(MMIDD\YY) 10-2.8-09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE MURRAY&MACDONALD INS S HOLDER..THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 550 MACARTHUR BLVD ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. COMPANIES AFFORDING COVERAGE BOURNE,MA 02532 COMPANY 75NHN A TRAVELERS INDEMNITY COMPANY INSURED COMPANY B KADY STEVEN DBA STEVEN KADY& SON MASONRY CONSTRUCTION COMPANY BOX 493 C FALMOUTH,MA 02541 -COMPANY D 4 COVERAGE 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 MURANCE 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. - CO POLICY EFF `, ,POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER DATE.(MMtDDWY) " DATE LIMITS" GENERAL LIABILITY GENERAL AGGREGATE $ COMMERCIAL GENERAL ,: PRODUCTS-COMP/OP AGO. $ CLAIMS MADE OCCUR. PERSONAL U ADV.INJURY $ OWNER'S&8 CONTRACTOR'S PROT. EACH OCCURRENCE $ FIRE DAMAGE(Any one fire) $ t MED.EXPENSE(Any one person) $ . AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT $ ALL OWNED AUTOS r BODILY INJURY(Per Person) $ SCHEDULE AUTOS "' BODILY INJURY(Per Accident)' $. HIRED AUTOS PROPERTY DAMAGE $ NON-OWNED AUTOS GARAGE LIABILITY ANY AUTOS AUTO ONLY-EA ACCIDENT $ OTHER THAN AUTO ONLY: - EACH ACCIDENT $ AGREGATE $ EXCESS LIABILITY } UMBRELLA FORM EACH OCCURRENCE $ OTHER THAN UMBRELLA FORM AGGREGATE $ WORKER'S COMPENSATION AND A EMPOLYER'S LIABILITY • UB-93IX7321-09 08-29-D9. 08-29-10 STATUTORY LIMITS X THE PROPRIETOR/ EACH ACCIDENT $ 500,000 PARTNERS/EXECUTIVE INCL DISEASE-POLICY LIMIT $" 500,000 OFFICERS ARE: X EXCL _ DISEASE-EACH EMPLOYEE $ 500,000 OTHER } DESCRIPTION OF OPERATIONS/LOCATIONSIVEHI6LES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE THE WORKERS'COMPENSATION POUCY DOES NOT PROVIDE COVERAGE FOR KADY,STEVEN. a r CERTIFICATE HOLDER CANCELLATION' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE TOWN OF BARNSTABLE BUILDING DEPT- EXPIRATION DATE THEREOF,THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT 200 MAIN STREET - FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF _ - - - - .ANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES. {{ HYANNIS,MAk 02601 AUTHORIZED REPRESENTATIVE ACORD 25-S(3/93) r Charles J.Clark ' 4083 .} r HIC Registration Complaints Page 1 of 1 The Official Website of the Office of Consumer Affairs&Business Regulation(OCABR) Mass.Gov > Consumer Affairs and Business Regulation ` Home> Consumer> Housing Information > Horne Improvement Contractor Program,> y. x HIC Registration Complaints Registration# 126014 Name STEVEN KADY City,State,Zip N.FALMOUTH,MA,02556'` Expiration Date 4/8/2012 Status Current No complaints found for this registrant. You can also view arbitration and Guaranty Fund history.. Back To Search ' ~ ©2010 Commonwealth of Massachusetts I http://db.state.ma.us/homeimprovement/licdetails.asp?txtSearchLN=25977 8/16/2010 Licensee Details Page 1 of 1 The Official Website of the Executive Office of Public Safety and Security(EOPS) Mass.Gov Home Public Safety P. 3 Department of Public Safety Licensee Complaints License Type Construction Supervisor License N 59847 Restriction I Name Steven L Kady ` City,State,Zip Falmouth,MA,02541 Expiration Date 10/3/2010 Status Current 1' No complaints found for this I...icensee. ` Back To Search r • i 4 ~ p t t http://db.state.ma.us/dps/licdetails.asp?txtSearchLN=CSL59847 8/16/2010 f s b oFWE r� PERMIT Town' of]Barnstable" *Permit# Expires m hs r m issue date ' `Regulatory Services � Fee, 010 7Z ma' Thomas F.'Geiler Director' 1639 �A p�m '� r BARNSTABLE FSII��I° 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 Reif X-Press Imprint Map/parcel Number Property Address °�7i � `� C��Tf l�l L Residential Value of Work. bk3�D.filU Minimum fee of$3S.00 for work under$6000.00 Owner's Name & Address!,_ /''Lt A> 41]/l of Contractor's Name 't>OA M 4 ) Tele hone Number Home Improvement Contractor License##(if applicable) i` 3f3b f " Construction Supervisor's License#(if applicable): Q~t! [ 5 ❑Workman's.Compensation InstiranceJ•"" Check ,.one: am a sole proprietor` ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp. Policy# a Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box)." c<, Re-roof(hurricane nailed)(stripping old shingles) All construction debris.will be taken to ,B/hCCA`' ❑ Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑, Re-side. • - #of doors ❑ Replacement Windows/doors/sliders. U-Value (maximum .35)#ofwindows *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 opy of the Home Improvement Contractors License & Construction Supervisors License is r uired. SIGNATURE: -... Q:\WPFILES\FORMS\building permit fo s\EXPRESS.doc Revised 072110 77le Co��morn ealth of Massachusetts bep�rtment of Industrial Accidents Office of Invesitigatians 600 Washington.Street Boston,MA 02111 "r4Ui rs' Compensation Insurance,Affidavit;-Builders,rCostractors/Electriciansli'Iumbers Appi-.cent Information Please Print I.egibl� Name (sinessKXgauizationllndi+jduaD.- 1 Y�tU�i[ &V!1.16M Address; a�bY - City/stabIziP: AM0TV AJI /A UM '444 Phone#: S8r-73 7-3 Z•V 17 Are you an employer?Check the appropriate box.: F, 1..ElI arn.aeraployer with 4. ElI am s general contractor and I Type of project(required):6 .❑New construction . lcyees{full and/or part—tune).* have hired the sub-contractors 2..trI am asole proprietor or partues-` Iisted on the attached sheet 7. ❑Remodeling i ship and have no These sub-contractors have employees' $: ❑Demolition uro.rkimgRx me in anycapacity-, employees and have workers' 9. Buildin addition workers'cans .itns�xra `comp-insurance.7 . ❑ g nce � � P . requind] 5. ❑ We are a corporation and its ME],Electrical repairs of additions 3.❑ :I am a homeowner doing all work officers have exercised their 1 1.❑Plumbing repairs or additions nrys;elf[No workers'comp. right of exemption per MGL ins ce required.]' c. 152, §1(4}.,and we have no 12.Eg- of repairs employees.fNo workers' 11❑Other Ccaw.,.insurance required.] 'Any appficmu dur checks box#1,must also fill ou-t the section below showing their workers'compensation policy information. liameoeKners woo sub roil this affidavit indicating atin g they are doing all woik aad then hire outside contractors mast submit anew a$idas•it indicating such- ICamractors that check this box must=ached an additional sheet showing the name of the sub-contractors and stale whether or not those entities have employees. Ifthesub-contractorshave employees,they must provide their workers'comp.policy number. I am an employer that is pros,&Mg workers'coitgwtcsat oa itisuraricce for irty employees Beloit'is thep©licy and job site Ir foYNlaiti!F,r!_ Insurance Company Name.- Policy #or Self--ins.Lit.#: - - Expiration Date: Job Site Address: CityfState/Zip_ - Attach a 1c.opy of the workers'compensation policy declaration page(showing the policy number and eipii ation date): Failure to secure coverage as required under Section 25A of IVIGL c. 152 can.lead to the imposition of criminal penalties of a fine up to$1„500.00 andlor one-year impr sonment;as well.as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the D.IA for insurance covverage verification. I do lterebn,rertr; er the ns and penalfies ofpediity that the inforinadarn prot+ided above is tru4 and correct S—igoture i Date: 'Phone#: b 3 7 3 4 offi al use orifj'. Do►rot write in this area,to be cotitpteted by city or town of ciaL a City or Town: PermitllAcense Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4,Electrical Inspector..S.Plumbing Inspector 6.Other Contact Person: Phone#- 6 - ws * STABLE, 6Ass. i619• Town of Barnstable �� prFD MA'S A ... Regulatory Services Thomas F. Geiler, Director Building Division Thomas Perry,CBO { Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Kfice: 508-862-4038 Fax:`508-790-6230 Property dwner'Must Complete and,Sign This Section,, If Using A Builder as Owner,of the subject property— ------ -`— -- hereby authorize o to.act'on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job).,. Signature of Owner Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. Q:\WPHLESTORMS\building permit forms\EXPRESS.doc Revised 072110 1� HET° Town of Barnstable Regulatory Services g Y a^ma Thomas F. Geiler, Director 1 '$pr039. A,� Building Division > Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 / www.town.ba rnsta ble.ma.us Off\: 5!!2-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION / Please Print DATE: �f JOB LOCATION: "HOMEOWNER" ; numb street !j village y � name home phone N j work phone tl i CURRENT MAILNG ADDRESS: j �1 i city/town st / zip code The current exemption for"homeow rs"was extended to include ow r-occu ied dwellings of six units or less and to allow homeowners to engage an individual fo hire who does not p9ssess a I' ense, provided that the owner acts as supervisor. DEFINITION OF OMEOWNER Person(s) who owns a parcel of land on wh h he/she resides or int ds to reside, on which there is, or is intended to be, a one or two- family dwelling,attached or detached structu s accessory-to suc .use and/or farm structures. A person who constructs more than one home in a two-year period shall not be consider d a homeowne Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she sh I be res o l6le for all such work performed under the building permit. (Section 109.1.1) r The undersigned"homeowner"assumes responsibility compliance with the State Building Code and other applicable codes, bylaws, rules and regulations. The undersigned"homeowner"certifies that he/sh understan the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with sa procedures and requirements. a F Signature of Homeowner Approval of Building Official Ir \ Note: Three-family dwelling' 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.L l -Licensing ofconstruction Superyisors);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 us/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 proce d against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit fonns\EXPRESS.doc Revised 072110 y* C 0 ' w Y - - - - fr, A • sw i C 1 a��uaelZs^ s ,n�a,+d for+ndiv Will use orl a +ste�t+ �fe �oow�c�ru L+ crnsc o► i;c ".I£ ourdretr:rn to end tit:t+ +a,f" �+1�ttcn date ,. to uinriins ;�fOr�the ex1 i �-d St ntlards Boar d of.Budd+ny;1 e COIyjACTOR r, l`of fieuld►►+g ltcgul? cons EMEi�T ,oa► ►ic Ashliu+tou r�:.1301 "6ME Imp'ROV A � ati'>os Registrat+on 138368 . :Trk ;1 r 13n� on, ;�.c Expira'lot 31� 011 1' k S t 6 / . LING& MoDEI N RE — BUILD r �turc i *JII,LLEN t V `sot�',ld�.+tl+ntil +gn t j �OUGLAS MULL E�1 '— c 2UBBY LN �'j3 Actn1" :� ' - �,2 u2 �r M�(ssachusett�- Dcpu+tmcnt of Public Safe" ardy ^ " Boil-(I of Buiid ervisor"L'icenae allil �nd:u+ds r Construction Sup r r r; Z. License:.CS; 81995; . 4 Restricted to;. 00 DOUGLAS W MULLEN 87 HICKORY HILL CIR OSTERVILLE, MA 02655 K}i Expiration: 1/23/2012 ��— Tr#: 16801 F, t (:umniis.iuncr :± V_