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BARNsr BM MASS, t639• Richard V.Scali,Director ♦� Building Division Tom Perry,CBO,Building Commissioner_ 200 Main Street,Hyannis,MA 02601 PRESS www.town.barnstable.ma.us � dJ Office: 508-862-4038 - To1 U�F0ax:,508,�790-6230 EXPRESS PERMIT APPLICATION - RESIDENTI�AL%NL:Y� Not Valid without Red X-Press Imprint TABLE Map/parcel Number Property dress /�' (? `J Ud�h 6'I? �i Zesidential Value of Work$_c92 UCVlinimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name IP>C a Y N ��/��G1� � Telephone Number,�' Home Improvement Contractor License#(if applicable)1®?,t Email: ���///G�,i��/�G��/�/G • GUh, Construction ervisor's License'#(if applicable). ���T —0 2 orkman's Compe 'on Insurance Chec e: am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name ::2/Q c/xv/o Workman's Comp.Policy# y Copy of Insurance Co nce Certificate must accompany each permit. Permit Reque 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 ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#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 Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: QAWPHLESTORNIMbuilding permit forms\EXPRESS.doc Revised 040215 s 27m Co]?1mD1LtwaM of Massachusetts Depa7enent of Iudkstyid Accidm& ©,, "ice oirInvestigat ons 600 Waskington Street Boston,MA 92111 . wwmmas&goWXa Workers'Compensation Insurance Affidavit: Builders/Contrack s/Electdcians/Plumhers Applicant Information Please Print Leo`bly Name Ate: I L 7 "go), 4 k, City/SS`-- Are yo an emplojer?Check the appropriate box: T of project I. I am.a with 4- ❑ I am a general contractor and I 9Pg (required): employs for pact-time)_* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or parr- listed on the attached sheet. T- ❑ Remodeling ship and have no employees Thesesub-contractors have g- ❑Demolitivrt waging for me in any capacity: employeesand have workers' 9. ❑Burling additions [No workers'oomp.insurance comp.i„�ri I , regairek] 5. ❑ We are a corpmatio n and its 10_❑Electrical repass 3.❑ I am a hwner Fall work of°M lsav�e exercised t� 11-❑Pl repairs or additions myself [No workers'camp_ right of exemption per MGL 12., of repairs insurance me&]T c.152,§1(4),and we have no e.mployew-[No wmkers' 13.❑other comp.mmmxz required-1 •say applicant Brat checks lox#1 nmst dw fill an the section below showing fludr waakere compensatioupolicy infhmnfloo Honoeoarm ors who submit this affidavit mdKxttRg they are doing all moaik and then live oaf conmcmas— submit a new affidavit iod ca— such- IConuacaus that check this boa mast wttached sm add tioust sheet showing the name of the sub-otitis a s and state whether armrt use ie tides bum employees. Iftbe sub-couhactors bare employees,troy nmtpwvide their workers'comp.policy number. lam an employer that is proizdtng n�orkers'compensation it4Sti tralrce for my employees. Blow is thepa Ucy aced job site irafa►rrvratiotn. /� �p Ias>aaace Ctnaparry I3am e: ®� �i �G + C� .6��W/`c Policy#or Self ins.Ile Job Site Address: e/I ee-I j€-JeQ 14/l1—< Attach a copy of the workers'compensation polio declaration page(showing thepolicy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the iWosition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment as well as civil penalties is 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 firwarded to the Office of Iuvestigatious of the DIA for insurance coverage motion. I do hemby caWfy louder th pains and nahiespfperjrrry that the inforntafiain.prmzded abmw is trueand correct. Date: Phone;9- 5�:02-� -a- e-1�Official ficial use only. Do not write in this area,to be completed by city or town afciat City or Town: Permit/License g Issuing Authority(circle one): 1.Board of Health 2.BuaMmg,Department 3.CityfPown Clerk d.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone 9: - - 6. a. '+ BAMSTABLE ' Town of Barnstable , QED MP't p Regulatory Services Richard V.Scali,Director Building Division Thomas Perry,CBO Building Commissioner . x. 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us , Office: 508-862-4038 Fax: 508-790-6230 6 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by.this building permit application for: 4 (Address of Job) Signature of Owner Date Print Name If Property Owner is applying for permit,please complete the Homeowners License'Ezemption Form on the reverse side. Q:\WPFILES\FORMS\building permit fonns\EXFRESS.doc Revised 040215 Town of Barnstable Regulatory Services �. Richard V.Scali,Director Building Division BA MSTnsta. ` Tom Perry,Building Commissioner nsass. $ A s639. 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was.extended to include owner-occupied 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 buildingpermit (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&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 040215 VILLA-1 OP ID:MF ,4coRo CERTIFICATE OF LIABILITY INSURANCE DATE 05/0412015Y) ��. 05/04/2015 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 endorsements . CONTACT PRODUCER Phone:508-771-3300 NAME: Olde Cape Cod Insurance Fax:508-775-3821 HONE a/C Ne Martha Findlay (PA/C. L Ext 300 Winter Street ADE-MADRESS: Hyannis, MA 02601 Martha J Findlay INSURERS AFFORDING COVERAGE NAIC# INSURER A:Essex Insurance Company 39020 INSURED Villani Construction Inc INSURER 13:Travelers Insurance P.O. Box 692 INSURER C: West Hyannisport, MA 02672 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. ADDL SUB POLICY EFF POLICY EXP ILTR TYPE OF INSURANCE POLICY NUMBER MMIDD/YYYY MMIDD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 3DWO339 10/10/2014 10/10/2015 DAMAGE RENTED 100,000 A X COMMERCIAL GENERAL LIABILITY PREMISESS(Ea occurrence) $ _ CLAIMS-MADE F_x]OCCUR MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO LOC $ COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-ONED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION WCTAI SU- X O R AND EMPLOYERS'LIABILITY B ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N 6HUB9982A27314 10/02/2014 10/02/2015 E.L.EACH ACCIDENT $ 5QOr000 OFFICER/MEMBER EXCLUDED? � NIA 500,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Roofing - Residential CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Barnstable 230 South Street AUTHORIZED REPRESENTATIVE Hyannis, MA 02601 maxfiaz5 F ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD VILLANI CONSTRUCTION INC. Roofing& Siding Specialists PO Box 692 West Hyannis Port,MA 02672 508-778-2495 1-888-766-3043 Member of the Better Business Bureau—Insured—Licensed—Free Estimate C�x�boda� Residence April 8,2015 86 Summerbell Ave. 508-778-0507 Centerville Ma. jarthurlane@hotmail.com DESCRIPTION Furnish and install the following, labor only to roof and side building at 86 Summerbell Ave. Ceterville Ma.As follows: Remove existing roof shingles. Install cedar breather. Install ice and water barrier to eves valley and penatration. Install snysectic roof paper. Install copper pipe flanges. Install and supply red copper open valleys, drip edge ,apron and step flashing. Install weaved,ridge caps.. Install Red cedar perfection #1. $19,500.00 Remove and install new pvc corner boards and lead flashing. $450.00 Remove existing white cedar sidewall shingles. Upper section. $2,800.00 Remove debris. TOTAL$22,750.00 —- - i -_— Lie CparrurraarccueizCt�i o�C�ac�zacaeGt�� . Office of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: ':,128560 Type: Office of Consumer Affairs and Business Regulation — — 10 Park Plaza-Suite 5170 xpiration .:47.21Y20=17 Individual Boston,MA 02116 - RICHARD VILLANI } RICHARD VILLANI ' 109 WAGON LANE HYANNIS,MA 02601 Undersecretary Not valid without signature u Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-0743 - 'rArr.ti60 RICHARD V111-0I PO BOX 692 West Hyannisport= 72 jflkA Expiration Commissioner 0612312016 ,> coot L �g Town of Barnstable *Permit# ✓" �3' 0� Expires 6 months from issue date. 1. Regulatory.Services Fee �3 s + BMWSPABLE 9 MAss $ Richard V.Scali;. Director u S FoI A•m C� ► Iz J�y Building Division Tom Perry,CBO,Building.Commissioner 200 Main Street,Hyannis,MA.026.01: NOV 2 1 2014 www.town..bamstable.ma.us. TO Office: 508-862-4038F� Fax; 08`7,90-6234 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY �� 7 //-- Not Valid without Red X-Press Imprint Map/parcel Number Z Z S� /0 62 Property Address (D. SV V14 me r 6c.11 : �V(' c�zv►�e�Vi�.� 1 W�� 6 2 6 3 Z Residential. Value of Work$ Minimum fee of$35:00 for work under$6000:00 Owner's Name&Address �({MC°5 66 svAw►crhel1 Ave ceo)crytlu, K44 0Z (o32 Contractor's Name VV1 Z° Owyicr Telephone Number 'v )-7� - Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am.a sole proprietor ®-ram.the Homeowner r ❑.I have Worker's Compensation Insurance Insurance Company Name Workman's.Comp.Policy# 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 _ ❑ Replacement Windows/doors/sliders:U-Value (maximum;.35)#of windows .#of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red Sand inspections required. Separate.Electrical&Fire'Permits required. *Where required: Issuance ofthis permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note:- Property Owner must sign.Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is -._ .. - _.. - - ... . .. -..._. _ _ ' required. SIGNATURE QAV PFILESTO ilding permit formslEXPRESS.doC Revised 061313 The Commonwealth of Massachusetts Department'of IndustrialAccidents Office of.Investigations 600 Washington Street Boston;MA 02111. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plu_tubers Applicant Information p Please Print Legibly Name(Busmess/Organization/Individual). M1161 C k1frle [7 :�9�ie Address: 5✓wfwrr ,�l HV>° City/State,Zip: evfl V : M4 02 3 L Phone#:`s0 7? OS cS7: Are you an employer?Check the appropriate box: Type.of project(regained): I.[]. I am a employer with 4 I.am a:general contractor and I employees(full and/or part-time).* have hired the sub.contractors 6• New construction . 2.ElI am a sole proprietor or partner- listed on the attached sheet. 7: 0 Remodeling ship and have no employees: These sub-contractors have. g, [].Demolition _ Working for me in any capacity. employees and have workers' 9 Building addition [No workers' comp..insurance comp..insurance.# re wired. 5. 0 We are a:corporation and its 10.❑Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their, .. `11.0 Plumbing repairs.or additions. / q myself. [No workers'.comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152, §1(4),and we have no employees.[No workers'. 13_�]Other Stke. L4j comp:insurance required I Gl Y t5 *My applicant that checks box#1 must also Ell out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are,doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number., I am an employer that is providing workers'compensation insurance for my employees. Below is.thepolicy a_nd job site information. Insurance..Company Name Policy#or Self.ins:Lic #::' Expiration Dater Job Site Address: City/State/Zip Attach a copy of the workers'.compensation policy declaration page(showing the policy number and expiration date). failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a . fine up to$1,500.00 and/or one-year imprisonment,as well,as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day:against the.violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance.coverage verification. I do hereby certi under the pains a penalties ofperjury that the information provided above/is true and correct Si atur : Dater Phone#: CSU�017 ' 0 S U 7 Official use only. Do not write in this area,to be completed by city or town official . City or Town -:PermitlLicense# Issuing Authority(circle one): 1.Board of Health 2-Building Department 3:City/Town Clerk 4.ElectricaI Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: If®ration 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 orm 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(o 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-contractor(s)name(§);addresses)and phone numbers)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability.Partnerships(LLP).with no employees:other than the members or partners,are not required to cant'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: slso be sure to sign and date the affidavif. 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 then. 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 additioi:;-an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current` policy information(if necessary)and under"Job Site Address"the applicant should write"all locations.in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be`provide.d to the . applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or.permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.. . The Office of Investigations would like to thank you in advance for your cooperation and`should.you have any questions, please do not.hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Accidents t of Industrial Aa D e Department Office of Investigations 600 Washington Street Boston,NM 0.2111 Tel. #617-727-4900 ext 406 or 1-87.7-MASSAFE Fax# 617-727-7749 Revised 4-24-07. . www.mass.gov/dia t s t BAHNSTABLF, '1 Town of Barnstable Regulatory:Services . .Richard Scali,Director Building Division Thomas Terry,CB0 Building Commissioner 200 Street Hyannis,'MA 02 M m S . � HY. �� 601 . . www.town.b arnsta ble.ma.us Office: 508-862-4038 i i Fax: 508-790-6230 Property Owner Must Complete and Sign.This Section If Using A Builder 5 I, `' "' ,as Owner of the subject property . hereby authorize �/((� 11 to act on my behalf, in all matters relative to work authorized by this building permit application for: Cep `cl M,, �6 SvGUGl9erhell �, �. (Address of Job) ` F . 2if/`/ • ignature of.Owner Date Ptint Name If Property Owner is.applymg for permit,please complete.the Homeowners License Exemption Form on the reverse side. Q MPFILESTORNMbuildmg permit fonvs\smokecarbondetectors.doc. Revised 050412 _ x_UrV_AX_ v$ . -Regulatory Services off Richard V.Scali, Director Building Divl<sion. snxivsrearE Tom Perry.,Building Commissioner KAM 200 Main.Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6.230 HOMEOWNER LICENSE EXEMPTION Ple ase Print DATE: JOB LOCATION: S vim i°�V bt _ �� number street village "HOMEOWNEW': �� •t.41w� y�. �Glyl� CSO'sU7 l name L home phone# �f CURRENT MAILING ADDRESS: S/ S VM `L ley- Goo, ,. CCU dP►vi�(c, � DZ63� - city/town :sate N. zip.code The current exemption for"homeowners".was extended to include owner-occupied dwellings of six units or les's 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 . eq //ements: ignature of Homeown . Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building.Code.Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner,performing work for which a building permit is required shall be exempt from the provisions of.this section(Section 109.1.1-.Licensing of construction.Supervisors); . provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." : Many homeowners who use this exemption are unaware that they are assuming the responsibilities of. a supervisor(see Appendix Q,Rules&Regulations for Licensing Construction.Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the,homeowner hires unlicensed_. persons.: In this.case,our Board cannot proceed against the-unlicensed.person.as it would with a Iicensed 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. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map ZZco", Parcel 06.1 Application # ®l ao Z 0 Health Division Date Issued 2 Z Conservation,Division Application Fee Planning Dept. _ n Permit Fee _ - / Date Definitive Plan Approved by Planning Board �� 2-A I L Historic - OKH _ Preservation-/ Hyannis Project Street Address �(0 -SU-kyX YYWY 6xA! Village ckx Owl t tc. _ Owner �G►(,e,✓i� Address Wes►/ 6xA /4Lt- Telephone Permit Request 3- Ce4l,) Coo q p L t L 611& r. r feet: f � i Square eet. st floor: existing proposed 2nd floor: existing proposed _Total new Zoning District Flood Plain Groundwater Overlay Project Valuation ODD 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_ ,- = o I-E Central Air: ❑Yes ❑ No Fireplaces: Existing__New _ Existing wood/boal stove:�,�❑Yew❑ No _., -n Detached garage: ❑ existing ❑'new size_Pool: ❑ existing ❑ new size Barn: ❑ existing LJ new we 0- Attached garage: ❑ existing ❑ new size _Shed: ❑ existing '❑ new size _ Other: A - Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ v : ' Commercial ❑Yes ❑ No if yes, site plan review# Current Use _ Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name C t l�c� e ✓Y Telephone Number s I V - 2-Sn3 Address 0� License# L0S-7-7 g pw�)W / '" b24 6 Home Improvement Contractor Worker's Compensation# �( O245 (4Qf 00/2- ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO Gov IZ SIGNATURE �� — - -DATE 1 Is 5 1�. p w ti FOR OFFICIAL USE ONLY APPLICATION# � :DATEE ISSUED 3 -,jdMAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: ;FOUNDATION FRAME •°INSULATION f FIREPLACE 4 ELECTRICAL: ROUGH FINAL 4 PLUMBING: ROUGH FINAL • .} PAS,-, ROUGHS: •r, z.. FINAL FINAL BUILDING t DATE CLOSED OUT ASSOCIATION PLAN NO. r .. - The Common ruenith of Massachusetts Print Form Department of Industrial Accidents t ( ; Office of Investigations I 1 Congress Street,Sprite 100 Boston,MA 02114-2017 • ww,V.mass.gov/ilia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legjblv. Name(BusinessiOrbaruration/individual): FRONTIER ENERGY SOLUTIONS Address:376 ROUTE 130,SUITE C - City/State/Zip:SANDWICH, MA 02563- Phone#:339-832-2823 Are you an employer?Check the appropriate box: Type of project(required): 1.. ✓❑ 1 am a employer with 8 4• ❑ 1 am a general contractor and i employees(full and/or part-time).' have hired the sub-contractors 6. New construction ` 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Rt modeling These sub-contractors have ship and have no employees 8. ❑ Demolition " workingfor me in an capacity. ' employees and have workers' Y9, [] Building addition [No workers'comp. insurance comp. insurance.$ required.] 5, [] we are a corporation and its 10.❑ Electrical repairs or additions officers have exercised their_ I i. Plumbing repairs � 3.❑ 1 am a homeowner doing all work " ❑ t; or additions myself No workers'com . right of exemption;per MOL y ( p 12.❑Roof repairs . 1 S2 't 4' an we have no t c �, d , insurance required.) employees. 13.❑✓ Other comp. workers' comp. insurance required.] t *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 ure doing all work and then.hire outside contractors must submit a new affidavit indicating such, tCoutractors that check this box must attached an addit on al sheet showing the nano of the sub-contractors and state whoher or riot those entities have employees. if the sub-contractors have etnployees,dtt:y must provide their workers'comp.policy number. ]am an employer drat is providing workers'compernatiun insurance for my employees, Below is the policy and job site . information. Insurance Company Name:AIM MUTUAL INSURANCE Policy#or Self-ins. Lic #,6012954012012 Expiration Date:7/25/20'12 l Job Site Address; City/State/Zip: Attach a copy ofthe workers'compensation policy declaration page(showing the policy number and expiration date).. Failure to secure coverage as required under Section.25A of MGL c. 1.52 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 ST'OP_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 hereb eerti under the eains and eenabies o er'uj that the information provided above is true and correct Signature: j ..-^1 Date: \ Phone#: 339-832-2823 Official use only. Do not write in this area,to be completed by city or town uffrciui City or Town: Permit/License h Issuing Authority(circle one): 1.Board of"Health 2.Building Department 3,City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector C Other Contact Person: Phone#: D�•rtr'�lhuv)>n•�ry'� CERTIFICATE OF LIABII:,:ITY INSURANCE 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). - VA9000ER � � CONTACT Rogers 6 Gray Insurance Agency ""Er PHONE PAS Inc (m. :)O. sxt): (AIC. Hoj: 9- PO Box 1601 1tl0"`dP: PROOVCEA South Dennis, MA 02660 CuccaleR log. "INSORED(S) AFFORDINO COVEAAOE HALC 0 IFrotier Energy Solutions LLC LNSUAEa A:A,I.M. Mutual Insurance Co 33756 Frontier — PHSORER Vi 1 39 Drive' INOURER o: Sagamore Beach, MA ' 02562' ,NsuA�R D, F nisuAER el. COVERAGES CERTIFICATE ITUMBER: REVISION NUMBER: THIS IS TO CERTIFY.THAT THE POLICIES OF 10SURANLE LISTED.MELON HAVE BEEN LS^sUED TO THE INSURED NA1,EO 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 AFFORDEDBY THE.POLICIES DESCRIBED HEREIN IS SUB:tECT TO ALL THE ERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICY NUMM R • POLICY EFF POLICY L'J'P - LIMITS ar TYPE OF INSURANCE (Hnicn/m-, 6earoPJYVYY GENERAL LIABILITY _ - FACFI 00CUM4Cc - 6 ❑"m"Itw.`I d OF'.7a'.,1s''v LIAEIL/TY - DA QM TO RENTED . - .. PREHIOeS{N rconco! 4 NED EMD (Any one PsrPcn). 4 . QPCnONAL&ADV INIURY ' ;Ml,L/cy-=; ;ATE:LIMIT AFPLI1,3 ER: I GENERAL A^+OAevA?E 4 CO!MP/OPAGO 4 E ; AUTOMOBILE LIABILITY - - Cm9sINEr,—me Lieu? Q 4 in.pea�i.denc) wri:AUTO _- SOOILY INJURY (pax DAecenl. ; ' CALL iWldHG A.JT+':Ls ' �ffiH)SWId:�'AU,:I'Q OPOTLY FNJURYIPa:'exidenU 11H71EI•N14ix>. (pse aCeiacn.) i 0 ' �W:Ql.ti1vRR'G�A4f'Ci'3 - ') ❑ 4 T , . ),�JlR¢d:sLLa LYAB ':•`Ymm �, EACH O(=W..We f - . lle=_"LiAO ❑+7LAIN3 MAIM - AOGAECAT& 8 ' WOFUWtS COMPENSATIONoTn- AND EbOLOYEES LIABILITY aY I.vcTY .en _ THE EE�f' IfTOkJ PARTItEftSi s.L.EACH AccLneNr s 1,000,000 - A EXECUTIVE TFICRF,S Ap.E y95 (+i 1#ZV 11, _ _ � l•^7 k}{ t:': ') 6014 F,L.O1SE"9-POLICY LIMIT s 1,000,000 ir r 0.7/25/2011' 07/25/2012 _ . • 9141. 01mmee^BA NN?LO?De p 1,000,000 ConantC ONRCRIPTION or OPERATIONe OR LOCATIONS. ALL MEMBERS ARE EXCLUDED FROM THE'WOR RSICOMPE14SATION POLICY. CERTIFICATE HOLDER CANCELLATION w CONSERVATION SERVICES GROUP SHOULD ANY OP THE ABOVE DESCRIBED POLICIES BE CANCELLED SEfeOBE THE_ WIRATION DATE THEREOF, NOTICE WILL DE DELIVERED IN ACCORDANCE WITH THE 50 WASHIJIGTO14 STREET POLICY PROVISIONS. WESTBOROUGH, MA 01581 4UTHOREm Demat irw.r R rt NoV, Q \ J Z Q © ~ a r 3 Q U U Z U1 O d x of s G" iu 4 i fl` tz a' License ar ccgistriltion valid far iodi ;id"I usv,01aly before the& i�irutian date. If found return to- before Offce of Con,unac9�Afi'niry O"d Busincss lteguf9atiau 10 Park Plaia,Sable 5170. Ooston,MA 02.1 iG "ti�aut sipnnt9i . - nli(1 a49.. 1 p. 1 OWNER AUTHORIZATION FORM I, (Owner's Name) owner of the property located at f , (Property Address) (Property Address) 1 , hereby authorize Lecq (Subcontractor) ' i an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. Owner's. Signature Date Assessor's office(1st Floor): // SEPTIC SYSTEM MUST BE Assessor's map and lot number INSTALLS Q14 COMPLIANCEE ypi TH Tp` ° Board of Health (3rd floor): W01 5WQ 0 Sewage Permit number ENVIRONMENTAL CODE � •7 e '; Engineering Department(3rd floor): / ,�i f �p ,��°►►��AA S&��"3'q, i assMASL tL S House number S;� O t639• Definitive Plan Approved by,Planning Board 19e APPLICATIONS PROCESSED 8:30-0:30 A.M.and 1:00-2:00 P.M.only p p' R OvTOWN OF BARNSTABLE a nsta. ,` ,t :'.�n I�DING INSPECTOR w�A#PfQATION FOR PERMIT TYPE OF CONSTRUCTION `O to lo �Cn is }H TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following�information: Location $ ►YI Pr e /�V 'e. C.: � � J Proposed Use Q� Zoning District- 1��-' Fire District5 CIE �sa 8� ��fY,mbEl1 A-'C Name of Owne fp11. r �. n�4�eY'�E ��� Address p � C1 3 Q�QRv6M Name of Builder Address Name of Architect l�r 1�1U��� ��tw Address Number of Rooms on E Foundation �`bL Exterior Roofing Floors ' Interior I Heating Plumbing lace Approximate Cost Z� Firep I a PP I Area Ne ��GA C�1H.a/ r Diagram of Lot and Building with Dimensions Fee i f OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable r rding the above construction. . v • Name Construction Supervisor's License ®f 1 0 T`� Er• LANs` JANES & VALLERI.E '' t _ No 3 4 6 2 6 Permit For" BU;ILD DORMERS Single Family ,Dwelling Jr f Location 86 Summerbel'1 Avenue �- Centerville ', k �. f & al_le` i re Lane Owner- Janes V � 4 r Frame 7 •-• ,� .! �� `�� _.., � Type of Construction , T =z Plot * Lot 4 7 Permit Granted October. 9 ,�19 91 Date of Inspection 19 rDat6 Completed 19 it CV win : ! �"� ��Kam. `/ - .+. � -. .•,. :�-. ` ` � , 65 �e�i 0� F! ~7 1, � _~*• t `x •`• thy` f f - .S aMr, 7 1Ir f III ¢%4C j • it � -�'. i 1.. I a rv'a I I �- , . III t F 1 IIIlI R • o � �� I I �� 1,, L _ I. II ell. "' `� ' 1 1 � ,