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0176 TERN LANE
a ,j .� Town of Barnstable t111C1ii1 g , n .�rxeae Post Ei This Card So That rt is Visible From,the Street Approved Plans Must be'Retained on Job andth�Card Must be Kept t M Posted Until.final Inspection`Has Been Made; y ` Where,a Gert ficate of Occu anc is Re uired `siach Bu�ld�n shall Not be Occu red wntil a final ins action has been madeY °` Permit jill� i <.. .,x. .,.; . . :. p q � '::..; >.?p.. sE,:s._ P <<a:. �,., � � Permit No. B-17-3371 Applicant Name: EBERT, MARK E&JOHNSTON,SHARON Approvals Date Issued: 10/05/2017 Current Use: Structure Permit Type: Building-Fence Over 6'-Residential Expiration Date: 04/05/2018 Foundation: Location: 176 TERN,LANE,CENTERVILLE Map/Lot 212-017 001 Zoning District: RD-1 Sheathing: krt Owner on Record: EBERT, MARK E&.JOHNSTON,SHARON 4� Contractor Name. Framing: 1 Address: 176 TERN LANE t '� Contractor Licerise 2 at P CENTERVILLE MA 02632 Est Project Cost: $2,000.00 Chimney: Description: Install 8ft fence - Perm►t.Fee: $35.00 ` Insulation: Fee Paid-f $35.00 Project Review Req: 3 Date: 10/5/2017 final: Plumbing/Gas k kf �� Rough Plumbing:' ,,Building Official final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorize fl. this permit is commenced within six months after issuance. Rough Gas: t All work authorized by this permit shall conform to.the approved application and the approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by laws and codes. Final Gas: This permit shall be displayed in a location clearly visible from access street or,road and shall be maintained open for public insp,'ectionfortha entire duration of the work until the completion of the same. > Electrical The Certificate of Occupancy will not be issued until all applicable signatures y the Building and Fire Officials are provided on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work: �� s 1.Foundation or Footing Rough: �. w... 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before`firestflue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to frame inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION 01 -1- Map Parcel Application # Health Division Date Issued VS-1 7 Conservation Division3(Appc�ati,on�Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board SEP 2 8 2017 7-0 tAJ&+ Historic - OKH _ Preservation/ Hyannis ��'a4'A,5 N8LE Project Street Address . Village �l L�Owner Address - Telephone Permit Request Square feet: 1 st floor: existing proposed 2nd floor: existing - proposed Total new Zoning District Flood Plain Groundwater Overlay 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: ❑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) Name �es�� Telephone Number' :Address,z C 20K License # �( ome Improvement Contractor# (Email//kk % 2& Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJE T WILL BE TAKEN TO G�J ,116 �� l � SIGNATU DATE t �� FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. f The Commoinfveafth of-Masssadiuse&s Department o}'r'n ustrid Acdderdds - -- Office of'bow6gations . 600 Washington Street A.__ Boston,MA021I1 wYvm maxLgvr1dia Workers' Ctmpensat m Insurance davit:Builders(ContractnrsMect cianslPFnmbei`s Applicant Informatign Please Print Nang psm� armatinnl[ncTna�ripaj e�_ Address: ' Are you an employer?Chet..kthe appropriate b Type of project(required): am general embractor and 1 6. ❑N. cons�iion I_El I am a employes with., 4. I a.g employees(full andfor part-time)-* have lured the sub-contractors 2.0 I am a sole proprietor orpartner- Listed onthe attached sheet, I- ❑Remodeling drip and have no employees These sob-contractors have 8_�❑Demolition war37ag forme in any capacity. employees and have wtxiere 9. ❑Building additiom jNo tvad=s'comp.insurance cop-ine MO--I required-] 5- ❑ We are a corporation and its. 10-❑Electrical repairs or additions as officers have exErcised their 3_El am.a fiomeovc�er doing all vroriE 1L❑Plumbingrepails or adt#itit5ns myself[No woiktrrs'camp- right of emealpfion per MGL 12.0 Roofrepairs inccrramre required-]i c.152,§1(4)�andwe haveno' employees-[No wodne& 13.0 Other cam-msrequired-] # nyWi�B�atdhedmboxtk1mastaLsafillouttfi�seetionbe=Iow�ntdagtlieirn+odcers'compeusatio-apnlseyinfnt�aa I Homeowner who submit dds E idavu ine g they aredokg su wady=4 then ham aatsi&contractors—st submit anew aSdmdt iodicam sucTL £Con=ctm tit cbeclr this box must sttadmd trm addifi—d sheet showing the amne of the sub-cootxsckns and state whelhec at not.those entities have ampkyees.Iftbesvb-ccntxctncshaveempiofea%theymustpm-,-! etheir workeo'gyp.palirynumber I am an employer that,ispratrridirrg workers'cots -stratus![inmirancefor uzy employees $elow is iite policy and jah she information. Insurance Company Name: Palicy#or Self--ins.Lic-4 Expiration Date: Job Site Address: Gity/5tafet .sp: Attach a copy of the workers'compensatiompolicy dec.Iaaratiion page(showing the policy number and expiration date). Failure to secure coverage as required.under Section 25A o€MGL c-15 can lead to the imposition of criminal penalties of a fine up to$1,50D:00 anNor one-yearimprisonment,as we21 as civil penalties.ia the form of a STOP WORK f1RDERand a fine of up to$250-00 a day againsf the violator. Be adiised that a cagy of this statement may be farwarded to the Office of In-estigations of the DIA for insurance coverage verifcaticn. Ida hereby cetflfp us f7latfFle infOrrsxa€&M-Prorrci abot%' bass MI carra't Date: Phoneir l3,focitd arse onlj. Do not write in this area,ire be campteted by tulip ortoirn official City or Town.: PermitUcense# Issuing Author€ty(circle one): 1.Board of Health 2.Building ntg Department 3.CityIrown Clerk 4.Electrical Inspector 5.Plumbing Inspector, 6.Other Contact Person: Phone#: - armation and Instructions Massach-ase#ts C=Umal Laws cbapinr M regoi=aU employees Yn provide workc&compensaton fur their employees. Parsaantto this side,an ezapTrryr=is defined as eveay person in the service of another Under any conaa ct ofhir`, express or irap iec,oral orwrftbm." An rsnplayer is defined as`°an mdxvidn parfnersh p.anociad on,m poration or other legal mti ty,or any two or more of the foregoing engaged-iu a Joint eAmpise,and inclndmg the legal=p=entaiives of a deceased employer,or the receiver or trastee of an ind" ' na p�ship,assochtinn or other legal entity,employing employees- However the ec ovTner of a dwelling house having not mare than three aparime�s and who resides therein,or the oc�of the - dwaIIing house of another who m3ploys persons to do maintman.=,caas$me ion or repair woiic on such dweIEMg house or on the grounds or bmlrmg app thereto shall not becanse of such employment be deemed to be an employer." M- GL dhapt=152,§25C{6)also sus that'every state or local liC ning agency shall withhold the issnance or renewal of a Hc— a or permit to operate a basiness or to construct burZdings is the commonwealth for nap applicant who has not produced acceptable evidence of cdmpr=m with the fncurance.covexage required_" AdditdonaIly,MCrL cbaptrr 152,§25C(7)states-Neither the comanaawealth nor my of ifs political subdivisions shall enter mtD any contract for the performance 0f1nblic wozkmOl acceptable evidence of compliancewith the msorance.. regrmh�ezffs of this chapt rr have Been presented to the cont-acting aoJhoi*." AppIrcantr , 'compensation affidavit co letel b checking the boxes�apply to your sifnaiion and,if e rke� Y, Y Please fill obf the wo mp mP, necessary,sopplY sub-confractor(s)name(s), addresses)and phone m—bez(s)along with their=tcFacate(s)of araes or Limited Liability Parfn-,Tips(LLP)with no employees other than the iztstaance. Limited Liability Comp (IZG� �' r members or parfncxs, re a not required to carrycarryworkeas comp ensa$an Zasmr-dnce. IF an LLC or LLP does have empIoyees,apolicy is regnireti. Be advised that affidayhmaybe mbmith'd to the Department of Industrial Accidents.for conf=ation ofi imivance covmrage_ Also besure to sign and dateth afdavit. The affidavit should beretmned to the city or town that:the applicaficn for the permit or license is being regve:ste-d,not the Department of Ind mTtrw1.A-=dmtF, Should you have any questions regarding the law or ifyou are repaired to obtain a workers' compensation policy,please call the Depmtneut at the ntna-ber]isind below: Self-ion=d cor¢panies should enter their s elf-insvra ce license number cn the appropriate line. City or Town Of iciaLs Please be stn a that the affidavit is complete and prhted IegribIy. The Department has provided a space at the bottom of the affidavit for you to fill ovt in the event the Office of Investigations has to cord a you regarding the applicant. Please be sure to till in the pem>it/licrose number which will be used as a reference number. In addition,an applicant that must submit multiple pernutlliceuse agglioat�ons in nay given year,need only submit one affidavit indicating caffeot p olicy infbrnation.Cif necessary)and under`Job She a_d 1&c&'the applicant Should write"an locations in (c¢y or town)-"A copy of tare-affidavitthat has been.officially stamped or mmiced by the city or tovm may be provided tq the ' applicant as proof that a valid affidavit is on fle far fufine peonies or licenses A new affidavit must be f Med oirt eachyear.There a home owner or citizen is obtaining EL license or permit notrelated pa any business or commercial veott= (it. a dog license or peanit to bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investiggions would like to thank you in advance for your cooperation and should you have an questions, please do not hesitate to give us a calL The Departmenfs addressy telephone and fax number: T C�a the of Massachnat#s. ' Departamt cif 1iidmtddArdent% Office of jtv'eKtk. ktio= �Q4 man t B Oil 11 TeL 617' -4 Qxt 406 Qr 1477 MA SSAF Fax#617` 27 7749 Revised424-07 ww mass-guvldia SHE Town of Barnstable "+Y~� Building Department Services Brian Florence,CBO V►sa 1 39. k � Building Commissioner F 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 as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) **Pool fences and alarms are the responsibility of the applicant Pools;_ are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner Signature of Applicant . Print Name Print Name Date Q:FORMS:OWNERPERMISSIONPOOLS Rev:08/16/17 r Town of Barnstable Building Department Services Brian Florence,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 s�axsTesr�. � - as.+as www.town.barnstable.ma.us 1639. �CU,,TFc N►a+" Office: 508-862-403.8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION �j DATE: Please Print ` JOB LOCATION: / number street village "HOMEOWNER": name home phone# ^-�-- work phone# CURRENT MAILING ADDRESS: �� �! city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under,the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigns "home caner"certifies that he/she derstands the Town of Barnstable Building Department minimum inspection procedures req ' rshe omply with said procedures and requirements. Sign re of Homeow er Approval of Building Official 'Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. , HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\MRESS.doc 08/16/17 Barnstable Fence Company Residential ♦ Commercial Paul Candito Owner Custom Wood♦Chain Link Vinyl Free In-Home Estimates Barnstable Fence.com 508.428.4200 BarnstableFenceCo@gmail.com 508.420.1985 fax 445 Osterville'West Barnstable Road Box 502 Osterville,MA 02655 r Legend o.�. �� Parcels Town Boundary # ' r � � Railroad Tracks -•�--�.-=-.- � �' `��1� �' �i � #€t�4 �''�t �� � � Buildings . nit- t Painted Lines - Y Parking Lots ....n` a , �''' 41 #'l i f`,' .. '" s.. a •r 0 Paved 774 ..___, — #23Q '� t r" w : Unpaved ... �•,sr r -•-� Driveways x A fffa Fe � i€756 {t °r Unpaved Roads x. , k 0 Paved Road -Unpaved Road ,,. k Bridge 798 #214 � � �� � � �� � ®Paved Median #.14�. Streams Marsh 4' Water Bodies #198:> ' �: ".' �-..�_ 4 fi �3�� � s� rya y,- - a^• tt #K 4 ' 1 12' .:fit #52': 344 Map printed on: 9/28/2017 This map is for illustration purposes only.It is not Parcel lines shown on this map are only graphic TO"Of Barnstable GIS Unit adequate for legal boundary determination or representations of Assessor's tax parcels.They are Feet regulatory interpretation.This map does not represent not true property boundaries and do not represent 367 Main Street,Hyannis,MA 026oi O i67 333 an on-the-ground survey.It may be generalized,may not accurate relationships to physical objects on the map 5o8-862_4624 reflect current conditions,and may contain such as building locations. Approx.Scale:1 inch= 167 feet 0 cartographic errors or omissions. gis@town.barnstable.ma.us grap Town, of Barnstable *Permit# I Ja-7- Z Regulatory Services Efee6mo frogs BARxsrAsiX MAas. Richard V.Scali,Director 039. Building Division Paul Roma,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number AI A —0/:z Property Address /7 6 %4/Q w dResidential Value of Work$00"!y *p yoo Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address /2A9,e/< 4!F3 F�7- 77 4- 72Fe c, L-4tise— CE•-,ram.-�> < Contractor's Name,�)/q V/y ��4[�2 p Telephone Number '?7 Y- Home Improvement Contractor License#(if applicable) /Z O y / Email: &4 V/dc'rc i+r �7- Construction Supervisor's License#(if applicable) CS O'?a lam(„ ❑Workman's Compensation Insurance ������ Check one: ❑ I am a sole proprietor ❑ I am the Homeowner OCT 2 4 2016 Q I have Worker's Compensation Insurance TO► N OF 8ARIV6►1�W { Insurance Company Name ASS c;['i'.¢ c� S/" �L 6 Yt'7�3 -Z k eV 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 4rA,14 ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) E'Re-side �• Replacement Windows/doors/sliders.U-Value . AR (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; Q:\WHILESTORMS\building permit formS\EXPRESS.doC 06/20/16 i0 4 a, WE Town of Barnstable Regulatory Services , NAM Richard V.Scab,Director %639. Nua Building Division, Paul Roma,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 I, AZAAe le �=QC 2 T ,as Owner of the subject property hereby authorize A�/�•` oe o to act on my behal f in all matters relative to work authorized by this building permit application for: /7G TZ- �-.cr C ( Cs-ti rEr (Address of Job) , **Pool fences and alarms are the responsibility of the applicant Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature-of Owner Signature of Applicant Print Name Print Name dS/Ago 6' Date ; y 4 QYORMS:OWNERPERMISSIONPOOIS Town of Barnstable Regulatory Services o�T1HUE Richard V.Scali,Director Building Division t 'Elm t Paul Roma,Building Commissioner MAM 639. & 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 sgRervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. °A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. - HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall-act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing.Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc 06/20/16 i Massachusetts Department of Public Safety " A Boars of Buildin� n,- -itandards License: CS-072866 3 Construction Supervisor DAVID A SAURO .. i' 163 TERN LANE CENTERVILLE MA 02632' = � A. ,- -� �— Expiration: �o:nmissioner 06/0612017 (62ecy»z»z,��uueul��o/ICJ/�lrc�elt.Office of Consumer Affairs&Business Reg�car�iculation� y9- @HOME IMPROVEMENT CONTRACTOR i3 -rti Registration: 170471 Type: \ },yExpiration; .10/27/2017 Private Corporation CAPE COD CONSTRUCTIONzSER/ICES, INC. -, DAVID SAURO ==t, 163 TERN LANE - CENTERVILLE, MA 02632c Undersecretary T7w Coairiromveakh qfMasyadrzisetft Department afradustrialAccadenYx OGC o �71f?�Fl7gatfl#7IS. A ' 600 Washuigion,S`trset Bastan,MA 02111 1VFtIi3itta=gov1dz l 'Workers' CampensafTIlI1.Iumn-ance Affidavit:Bmlders/Ca 1{TaCtiirsJEect CtcIdIIrJPhEmbers AppIi=m#Infarmafian Please Print Na= : e gooE C&Z C6 A!Sxr- Address !(o.3 Teti, Cit�I1 atr1 �TEi yi-Cf�o / �a�G.�- Phan 7?Y'�1 ?•�d o Are You an employer?:{keekthe appropriate box: 1.E I am a 1 with. 02 4 ❑I am a general contractor and I Type of project uctio red}: employees(and br pad time * have hiredthe sdb-coatmcfars 6. ❑Itietiv oons�rocEror�2.❑ I am a sale proprietor orpartaer- listed on,the attached sheet. 7_ ❑Remodeling s*and have no employees M e smb-co tractors have S_ ❑Demolition worldng forme in any capacity. employ and have wormers' 9..ElBuilding addiI ica [NQ Wodonrs'Camp.insurance comp-msura. ce 1 - required-] I ❑ We area corporation azid its 10-❑Electrical repairs or additions 3111 am a homeovner doing all work offices have exercised their 11_❑Plumbing repairs or additions a workers' 7_ right of emempfion per M(M myself eq d]y c.152,§In aadwe have ao ❑Iioofrepairs employees.[No wod=e 13-Q fluter 001-L T�i.¢Ti o�.s cone_mmurance required-] '$ay aW ic 6satdet3mbox fI mast also f�ovtthe sectiaabeIaa sirafiiug d1PRwo�cecs'comp��fi�,a•paTicgi�oemsuon Samem meSwho subnxd do rfd2vif ubficstmg they smdmag agwal Rmd den lam auWdecanb=t=srMst sab=t zIMWzffidXeIt'fndlcahm 56d ICar acfoistbze cbeckt&bmt must attached saaddiiinnal sires shouTagftnameof the sab-caoxscmrs snd stsFewhethec arnotthose ea¢tksh.wm employees.Iftbesuh-raatxct=havee=.pIcyw%t6e}'mustpmvide&ek workess'tomp.pGlkyaumiser I am all eiiiger float isgrauiiiirig rorrrkets'coerrperesrdirxrc iiisaratica f ar m}T earpfa}�ees B�toav is 4ihe prr�icr•ruzd f o7a sites FqfbrrnahbiL Insurance Company Name: X�!SS G re q t-e eb eoov®L 6 yd!F-A,S Policy t�L or Self-ins.Lic- F-TirationDate: Job Site Addre= !]& T?Av .�9�/Y Cityl5tatet2�rg:_�!etiT��'y�!(• •07� G•�G Attach atopy of the workers'compensationpcdicy declaration page(showing the poficy,number and expiration date). Failure to sewn coverage as required under Section 25A of MGL cL 1572 can lead to the imposition of criminal penalties of a fine up to$00DOD and for onii y6ir impaismazent,as w8U as civil penalties in$re foan of a STOP WORK€?RDER and a fine of up-to 0-00 a dap against the violator. Be advised ffiat a copy of this statement maybe forwarded to the Office of Investigations ofl a DIA for insurance coverage verifiratiam I do heral Yyujtdff tTfepaiiis arrd penaL�ies a. F r3'fhatthe iia arRrarfraiiprm dabaw�s ig hiss acid carrect 7$jvs��afrer : / Date G Z.2 Y A;W� Pi»i�_ 77 Ofi%dd we a nIr. Do art write its dib area,tit be camp&&d by rip artaprn offic&I M'or Town: PermitT&ense:9 Issuig Authority(dr le one): L Board of$eah€i I Builffing D4wl meat 3.Gtyffmm Clerk 4.Fectrical Inspector S.Plumbing Inspector b.Other Com#act Person MOW#- Information and Instructions ' r3Tnc s Genraal Laws chaps M rues all emplay=b provide wus'campeasafion far$nen-employees. . Pursaa=Hn this sue,an ezvhg em is defined as" ery personin$f a service of another under any coutract cfhur, esp}ress or implied,oral or VZftt :CL" An.errrplaym-is defined as"an individual,pmta rshT.asso�atian;coipor-&=or other legal eat ty,or any two or mare- are . of the foregoing=agaged in,a joint uprise,and including title legal regresea...iiyes of a deceased employer,or the receiver or trastee of an mdiviftA paztoeaship,association or otherlegal Cathy,employing employees- However fits owner of a.dwelling Manse having not more than three aparlmeu and who resides ffierem,or the occagant of thM - dwelling house of another Who employs persons to do maw .ce,constra_�tion or repair woik.on such dwelling house or on.the grounds or buadmg appmt= thereto shall not becanse of sack employment be deemed to be an employer." Mcg-cbaptes 152,§25C(6)also states that"every state or local HcenZmg agency shall witiihoId$ire issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicani:who has notproduced acceptable evidence of cumpM_Mm with the k=ance_covcJrage required_" ionally,MGL chapter M,§25C(7)states"Neifher the-rmweahi,nor of its political subdivisions shall Addit enter into any coat and for the per�ance ofpublia wodcuot acceptable evideam of compliance with the fimmrmr,6._ requn emus of this chapt=have been p=CE±E-d fn the cones-�, anihortty." Applicants Please f of out the worloss'compensation affidavit completely,by chmldng&e boxes ffiat apply to yo=situation and,if necessary,supply sob-c tor(s)name(s), (es)and Pie mxrmber(s) along with their c: t fcat*)of mmmmce. Limit$d Liability Companies(MC)or Limited Liability Partnerships(f I P)witb-no employees Other than the members or partners,are not rued to cagy worke&compensatim ins¢c-race. Eau LLC or LLP does have employees,a policy isregnfiT4 Be advised that this affdayit maybe sabnaRtedtothr,Depacimentoflndnst<ial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retied.to the city or town that the application for the permit or license is being reque�not the Department of Ldztstrial A ccide goaldyou have any gnestions regatdIDg the law or ifyon ale regairedia obtain a wodCers' compensation policy,please call fie Department at the number listed below. Self-lured companies should emtrr their self-insor ce license number an.the appropriate line. City or Town Officials f - Please be sore that the affidavit is complete and primed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office oflnvesiigatios has to contact you regarding the app ca t Please be sure to fill in the pe�Jlicense munber which will be used as a reference number- In-addition,an applicant that must submit multiple pe=Vhcense apph ations in any given year,need only submit one affidavit indicating=Mt policy information Cif necessary)and under"Job Site Agd ess"the applicant should wi3te"all locations is (may Or town).'A copy of the affidavit that has been.officially stamped or maziced by the city or town maybe provided in ffio ' applicant as-proof that a valid affidavit is on file for furore pezmi�s or licenses Anew affidavitmust be filed oit each year.Where a home owner or citizen is obtaining a license or permit not related in any businessor commercial ventnM (i-e. a dug license or permit to bum leaves eta_)said person is NOT required to comPIete this affidavit: The.Of of Investigations would h1cc.to ffimk you in advance for your coopeaafion and should you have:any gaestious, please do not hesitate to give us a call. The Departmeafs address,telephone and fax number_ commmwesl*of M&SMchmdt . . IIega�a��xf lridrt��ak A�i�.c�t� OEM=of XnVe&tigktia= �Q4an Bt MA QIII Tot.4 617' -4900 eft 4-06 or 1-977 lv4 A CAM Fax#617 727 7M Kavised424-071z,a gldhL A CERTIFICATE OF LIABILITY INSURANCE oATE(MM/DD/YYYY► 0912112016 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, subjed 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 CONTACT Cowan Cowan Insurance Agency,Inc. PHONE .978 372-1451 FAX 359 Main Street MaL 978 521-4669 Haverhill MA 01830 la cowanlnsurance.com INSURER S A FORDING COVE COVEgAGE NAIC H INSURED INSURER A•Associated Employers Insurance Corn an Cape Cod Construction Services Inc. INSURER Insurance Company IN R • 163 Tern Lane Centerville MA 02632 INNRER 0: INSURER E COVERAGES INSURE F 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. TN—SR TYPE OF INSURANCE DL UiJ-13IRPOLICY POLICY EFF POLICY EXP GENERAL LIABILITY NUMBER LIMITS EACH CCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED CLAIMS-MADE ❑OCCUR $ MED EXP An one $ PERSONAL&ADV INJURY GENERAL AGGREGATE fA REGATE LIMIT APPLIES PER: Y PROIF;rT LOC PRODUCTS-COMP/OP AGG ILE LIABILITY $ COMBINED SINGLE LIMB 1 0011000 UTO ALL S NED x SSUCTHEDULED 6232834 BODILY INJURY(Per person) $ NUTOS ED031�24/2016 03124/2017 BODILY INJURY(Per accident) $ AUTOS x AUTOS PROPERTY WWGE $ UMBRELLA LIABHCLAIMS-MADE OCCUR $ EXCESS LIAR EACH OCCURRENCE , E A GREGA g WORKERS COMPENSATION AND EMPLOYERS LIABILITY x WC STgTU- OTH- ANY PROPRIETOR/PARTNERIEXECUT Y N A OFFICER/MEMBER EXCLUDED? N/A WCC5011292012016 08/25I2016 0812512017 E.L.EACH ACCIDENT $1000 000 (Mandatory in NH) Byes describe under E.L.DISEASE-EA EMPLOYEE 1000 000 E RI TI F OPERATIONS below E.L.DISEASE-POLICY LIMIT 1000 000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Addidonai RemaAta Schedule,it more space Is required) Residential construction management CERTIFICATE HOLDER CANCELLATION Town of Barnstable SHOULDANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE 200 Main Street THE EXPIRATION DATE THEREOF, NOTICE WELL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601 AUTHOMMO REPRESENTATIVE Fax: 508 362-9001Zf ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo gistered marks of ACORD �VE r Town of Barnstable *Permit Expires 6 months from issues Regulatory Services on _ ' v �A 1639 Richard V.Scali,Director 2015 Building Division Tom Perry,CBO,Building Commissioner TOWN OF BARN, STASLE 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number /,21Lr17 Property Address /�(c, �� ''� &M"Zr Residential Value of Work$_%&,r 600 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address AA,eA 6 be., 7— Contractor's Name 017 V/ 6 Y,9 Ve 10 L Telephone Number 7 Home Improvement Contractor License#(if applicable) Z�2 V 2/ Email: . Construction Supervisor's License#(if applicable) 6,?C99 6 ❑Workman's Compensation Insurance Q Check one: ❑ I am a sole proprietor ❑ I am the Homeowner 2� "I have Worker's Compensation Insurance , Insurance Company Name A�, Asso i"-f-rAE�Z Workman's Comp.Policy# �G��(' '�j�/' ®1C7�.,X0/ 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) Er Re-side ❑ Replacement Windows/doors/sliders..U-Value JC7 (maximum.32)#ofwindows #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: Q:\WPFILESTORMS\building permit forms\EXPRESS.doc Revised 040215 t Massachusetts Department of Public Safety Board of Building,,Regulations and Standards License: CS-072866 � Construction Supervisor t DAVID A SAURO 163 TERN LANE t C:ENTERVILLE MA 0 Expi ration: • � r . Commissioner 05/06/2017 � C�ee.(pon��u�ecuecc��,c��/�c�uarrc�urrel/ 1 t Office of Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR t egistration: `:1704,71 Type: :C :Expiration 10/27/2015 Private Corporatic GAPE COD CONSTRUCTION SERVICES,:INC AVID SAuRO ' 1 3 TEkN L-NE *„ G � IIZ GENTERVILLE,MA 07.632:. t'indersecretary Ft t r r CERTIFICATE OF LIABILITY IIVaIJF��ING --==---- E DATE(MM/DD/YYY'i) THIS.CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION.ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATI'E(_Y OR NEGATIVELY. AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY.THE POLICIES BELOW. THIS CERTIFICATE OF IN$GIRANCE DOES NOT GQN$TITUTE A CONTRACT BETWEEN THE ISSUING INSURE:R(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder l.c certain ADDITIONAL INSURED, the policy(ies) must be, endorsed. If SUBROGATION IS WAIVED, subject to� the terms and condiltlons of the policy,certain policies may require an endorsement. A statement on this certificate does not confer WAIVED, rights to tblt certificate holder in Iheu of such endorsem6rit(s). PRODUCER CONTACT Cowan Insurance Agency,Inc. NAME; Larry Cowan - 359 Main Street (ACC,19..o,E_'. 978 372.1451 i G`N�i. 978).521-4f69 -- E•MAIL tar cowaninsurance.com. Haverhill MA 01830 �c��-�°' ' INSURER(SIAFFORDINGCOVERAGE . : _NAIr, INSURED - INSURE A: Associated ElnpiOyerS Insurance Company INSURER B: Safety Insurance Colrl an Cape Cod Construction Services:Inc. INSURER C 163 Tern lane ' _ Centerville MA 02632 INsuaea D R — - INSURER E COVERAGES INSURER F:. 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 POUCYY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS j CERTIFICATE MAY Ot ISSUED OR MAY PERTAIN 'THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED,HEREIN IS SUBJECT TO ALL THE TERM:;, EXCLUSIONS AND COf�DITiONS OF SUCH POLICIES.,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN SR AI)47L SUER TYPE OF INSURANCE a+' ima POLICY NUMBER POLICY EFF POLICY EXP - GENERALLIA131LITY I LIMITS COMMERCIAL GENERAL LIABILITY t EACH OCCURRENCE _ $ DAMAGF_TO RENTED CLAIMS-MADF� OCCUR EMLSES(Eriotcurcancn) $ MED EXP An one 'arson $ --- I ; PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIM T APPLIES PER. t _-- GENERAL AGGREGATC.i $ POLICY PR I PRODUCTS.COMP/OP AGG $ -- LOC AUTOMOBILE LIABILITY ): i $ — COMBINED SINGLE OMIT B ANY AUTO (EaaccidenU _ g 1'000rOOO " a _ ALL OWNED SCHEDULED ' BODILY INJURY(Per person) $ AUT03 AUTOS 6232834 I 03124/2015 03124I2016 BODILY INJURY Per accident) $X: HIRED AUTOS NON-OWNED { AUTOS PROPERTY DAMAGE -- t (Per accidents $ UMBRELLA LIAR I i $ _ 'OCCUR EXCESS LIAR CLAIMS MADE EACH OCCURRENCE $ DIED TE !I j AGGREGATE $ -- WORKERS COMPENSA ION $ AND EMPLOYERS LIABI ITY — X WC STATU- UTH. �I ANY.PROPRIETOR/PARTNERIEXECUTI Y/N ORLHMI- A OFFICER/MEMBER EXCLUDED? Y A (Mandatory in NH) WCC5O11292012014 08/25/2015 08/25/2016 E.L.EACH ACCIDENT _ $1,000 OOO If qes,describe under I = E.L.DISEASE-EA EMPLOYEE $1 OOO OOO DES RIPT N PE ,TIO be ow i E.L.DISEASE-POLICY LIMIT $1 OOO 0OO DESCRIPTION OF OPERATION i/LOCATIONS/VEHICLE jAttach ACORD tat;Additional Remarhe Schedule If,more apace is rbquired) ^ ' 1 I s Residential construction. lane ement CERTIFICATE;HOLDE :. I I - -- I k •� CANCELLATION Town of Ba stable K i+ I SHOUL n D ANYOF THE ABOVE DESCRIBED POLICIES ES B CANCELLED ' ' E C C LED BEFORE - 100 Main St eet � ! � �, '` � THE EXPIRATION <pATE THEREOF, .NOTICE WILL.BE DELIVERED ;IN, nI' ACCORDANCE WITH THE POLICY PROVISIONS. i Hyannis,M d2601" AUTHORtZED REPRE NATIVE i 612 r I Fait r 01988-2010 ACORD CORPORATION. All rights reserved, i. ACORD 25 2010/05 J. ( ) lthe ACORD name,and.logo are rag stered.marks of ACORD I S I 1.7te Comrnonivealth of Vassachusetts Departimum of Indushial Accidents Y - Q ['e ofI mw_stigad&nS ' :- 600 Washington Street � ,f y: . Boston,CIA 02111 ' ivmv ma&Lgov/tin Workers' Compensation.Insurance Affidavit:Builders/ContractursJEIecfr clans/Plumbers. Applicant Information Please.Print Legibly Name(F3uss�esslOFgan�tionfladividoal}: (�����C'� �C��f!�%�UL'%ilrl�. � i`i/>C�� Address- Ehi�Via^�.�G e /�� Ph e 4 tify}Sfi.at�l�ig: (.� a4G Are you an employer?Check the appropriate box: Type of project(required): . L vI am a em la er with A 4. ❑I am a general contractor and I P Y 6_ [-]New construction employees(fun awVor part-time)* have hired the sub-contractors 2..El I am a sole pmpaie#or•orpartner- Iistied og the attached sheet - g slip and have no employees. These sub-contractors have g. ❑Demolition working forme its any 1 employees and have wodcers' orb y capacity. - 9. ❑wilding addition. [No u-ork ers'comp.insurance comp.insurance rewired_] 5. ❑ We are a corporation and its 10❑Electrical repairs:or additions 3.❑ I am.a homeoumer doing all work officers have exercised their 11-❑Plumbing repairs or'additiom myself[No workers' _ right of exemption per MGL 12.❑Roofrepaiis , insurance required.]F a 152,§1(4k andwe have no employees_[No workers' 13.❑Other' comp.insurance required.] •tlay appKcaut that chedrs boa P1 rmosY also faloot;the section belm showing their w0aere compensation policy informstiom ` Mnveoaraers who subaait this affidatgt hufic t;.,g they am doing all waak aud,then hire outside contactors mast submit anew affidavit indicating Such.' fContamrs that check ibis boa must attached an addilianal sheet dhowmg the aanve of the sub-contzctm and state whether or not those entities have ' empkoyees.If the sub-c=tzz=Eshave employees,they musrpmtm�ide thew umtkea'camp.policy number- - I am an eerpkPjier that ispr4n dit>it�orkers'corrgrerrsatiaii insurance,for my*eniploy�es B'etow is the policy rindiab site €nforrnation. Insurance Company Name: /W'� 61f''016'yerS lij✓/®9�C1 0-10 kk'17_ ' Policy,At or°Relf-ins.Uc. t�� t! ,}�9 Expi>ation Date: Job Site Address: � City/State/Zip: eel re.e�1� • s C �' •%L Attach a ropy of the workers'compensationp.olicy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A o€MGL c 152 can lead to the imposition of nriminai.petsalties of a fine up to$1;50D-00 andlar one-year-imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to WO-00 a day against the violator. Be advised that a copy of this statement:maybe farvrarded to the Office of ' Iuvest gati=ofthe DIAL.for insurance coverage'werifitation ' It Hereby c f}1 uatder tine pains ar �alliies o,�pet�ury thatthe infionnatiortpnat tad abot�is true and correct Sitaahsre: Date: Phone is Official use only. ,Do not write in this area,to be completesd by city Orion*ofeiat City or Town: P'ermitJLuense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityffovm Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: Information and lastructions Massachusetts G&amal Laws cbaptmr 152 regan-es an employers to provide workers'compensation for their employees. Pn s aatto this statufc,an.empIayea is defined as.--every Person in the service of another under any contact ofhire, express or implied oral or wriffrm�" An Mayer is de5ned as"an individual,pazinersii;p,assocjatjon,corporation or other legal entity,or any two or more of the foregoing engaged is a joint enterprise,and mchiding the legal representatives of a deceased employer,or the receiver or trustee of an individml,parhamsbip,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 - dweIling house of another who employs persons to do maintenance,construction or repay work on such dwelling house or on the gro=ds or building appurtnnanf.thamfD shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also stems 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 insnran ce.coverage required." Additionally,MG1,chapter 152, §25C(7)states"Neither the commanwealth nor a'ny of ifs political subdivisions shall enter into any contract for the performance ofpublic work until acceptable evidence of complia ace with the ins rraan c6.. rPZ irem,ents of this chapter have been presented to the contracting authority" AppHcaufs Please(fill orb the workers'compensation affidavit completely,by checI®.g the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s), address(es)and phone numbe (s)along with their certificate(s) of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not rimed to carry workers' compensationinsurance. If an LLC or LLP does have employees, a policy is rmpa-ed. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confirmation of m uran ce coverage. Also be sure to sign and date thhe affidavit The affidavit should be retamed to me city or town.that the application for the pemsit or license is being requester not the Department of jndn trial 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-brined companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sore that the affidavit is complete and pried legbly. The Department has provided a space of 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 pmrm liceme number which will be used as a reference number. In addition,an applicant that must subm:rt multiple pennitllicense applications m any given year,need only submit one affidavit indicaimg currant policy inf6ri ation(if necessary)and under"Job Site Address"the applicant should write"all locations in (cry or down)_"A copy of tht-affidavit that has beea officially stamped or marked by the city or town may be provided to the applicant as prcof that a valid affidavit is on file for fume permits or licenses_ A new affidavit must be filled out each year.Where a Lome owner or citizen is obtaining a license or permit not rel atEd to any business or commercial venilse a dog license or permit to bum leaves etc.)said person is NOT regcdred to complete this affidavit The Office of Investigations would at 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 m=ber. The mwealtb�of Mamachusetts , Deparbnent cif hidustzal AGaidents Mtee ofve�fig�tzo �Q��ashingtQn t BQstou.,MA Q111 T�1, 617 727-49QO c�xt 06 or 1-M-MASSME Fax 9 617`27-7M Revised 4-24-07 ma..ss.gavidia. r r a • - • SARNBTABLE. • MASS. � se39. Town of Barnstable �� 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. as Owner of the subject property hereby authorize � 1� � to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) M Signature of Owner Date Print Name r. '` i 4 r -,F If Property Owner is'applying for permit,please complete the Homeowners License•Exemption Form on the reverse side. fff I Q:\WPHLESTORMS\building permit forms\EXPRESS.doc Revised 040215 Town of Barnstable , Regulatory Services , ��THE Richard V.Scali,Director Building Division " anartszas>.E Tom Perry,Building Commissioner MAW 63g6 1. 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 su ervisor. 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 ep rmit (Section 109.1.1) Y 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.doe Revised 040215 Assessor's map; and lot number Rl s t SYSTEM Sip°TIC MUST BE,` 4, IN: COMPLIANCE w INSTALLED wage Permit number . ......: ,ftMC... Q ..r . ..��...... .. It STA?E Se VdITH APTICLE T®WN " �FTRE?o�` T T CODE AND . TOWN° O BA'R � C7 i BABBSTADLE. AM opY'0"� 3 �`- BOLDING IH"SRECTOR APPLICATION FOR,`PERMIT TO .. //: �•• / d S V J C!.... o TYPE OF CONSTRUCTION .....P .! .......... ............ ............................................... .......................19'7 .: TO THE INSPECTOR OF BUILDINGS: j The undersigned hereby applies for a permit accord�i/ng� to theJ follow,ing) information: Location ........1.7.4�P..... ..� �. .'!,...... k.......... .t .Te.� :: .!. ......./.sl.. ................................ ................... ProposedUse ....�—nm ; ............................... ........................ .................. Zoning District .. . .^/................................ ....................Fire District ....0 .......................................................... Name of Owner n.. �y.►Ylonlo! ..JA-:: .......Address Jl ���� ... .... P+^cJr../•................... Name of Builder .e pll7J fJ��� 11?C' ...5. C.G:......Address h.....✓lel;..... - -S ,:. .......................................Address ......:............................................................................. Name of Architect ........./Va.u.�C Number of Rooms ............r...............................:....................Foundation A. ...... .....r.w...F .....c.�..�.9..�.......t..:...... Exterior .... .k4u. Roofing ..0`?.3.. �' .................................................... :...................... Floors ..........Interior Heating l a� '� /l1.. N '� ........................................................................Plumbing ..................................... �a Fireplace ...... .........................................................Approximate Cost.........................:......................................... Definitive Plan Approved by Planning Board --------------------------------19________. Area ...3.�.®.... ` ... . ./-- ...... o� Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH t r tj 4,u -30 i Ja _ -I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. w Name � .. .. . . O r I-S Pendergast, Raymond ` ' No 19�41.... n=,initfoi ..... 1_____ ----..-...--,-.-----~—.—'.---..— ' / 176 Tern ��° ' ! Location_ — —^—'~'—'.—_r--^—~^^'^^'----_' ' L ......................... ............ .......................,____._. . Owner --.�����P��./�������9���---..--... Type of Construction —..�we��. ___._ . ^ ' .................:....................... ........ ............................ Plot �� ' | ^ ^ ._---.~---. ----^-----' ~ . . � ~ � eku��� �� �� Permit Granted — em----..-------.�V Dote of Ins --------. �.r—.. .1g . - / Date Completed — ---_lA ......... ' . . . PERMIT REFUSED .......................... lg ' �—...—...--......... ' t . � '.......................... ..,........~............................ ' ^ .—~-.,..,~..~.-.,.^-.-. -.--~'-....—.~..—' r � / ._.^._ _�,_,_,,.,c,._,__``,.,�_.__. . \ . ` ._~_,,^,, ..................................... .................... . ^ —`' � . ' . � ' ' � Approved .................................. ........... . )V ----------.----.---,—.—,.~.,.�. . . . -----------..—~—..---...—.~..—. ` ' . , ^ . � � ] � ' Assessor's map and lot number ,r... "✓�.` � �.. Sewage Permit number ........................,.,. :..........,....... °*7NE.T°�� TOWN OF BARNSTABLE 9� WMILL 0 a9- BUILDING INSPECTOR APPLICATION FOR PERMIT TO ., /TPA ... " ®ST i...............................................v :....................................... i TYPE OF CONSTRUCTION .....!*? c�a ....:�.'..!¢ .. . ........ a.... l/.......................1 .. TO THE INSPECTOR OF BUILDINGS: -The undersigned hereby applies for of permit aacccord�i/ng, to the/ following ] information: Locdtion ........�.. .�!.......� !�A .!1�..... `................C, ,n Tr,f;cJ. ....... ..... / ................................ ................................... ProposedUse ...s....! .!a?..t,".......................................................................................:............................................................... ok— I Zoning District .......................................................Fire District . /I!). ...., ....F. ......:.f................................................................... Name of Owner f r,.(jr1 a Irtonld I"F3JC��C �: f r!O ....................... ....................Address ....,...,....................... ......... ......................................... Name of Builder ?ti! !1�.... ,??(ar!?! "oxtrA Sra r�<_ Address .. �?..=`l uOv 1 A Rd. fy,S/^wl S Y ................. a ............... Y ........ .. .......................` ... Nameof Architect /1�n,t . -.......................................Address .............................................................'........................ Number of Rooms j....................................................Foundation ��� /�aIC t-�// Fv�-3 A l -v . Exterior ......5.A.OXPS............................................................Roofing .,7.: .' .. SOh!9/,!`............................................. Floors Interior �o ..................................................................................... .................................................................................... Heating n 10�! �� ...........................Plumbing ......N�J.. ,r........................................................... ....................................................... itJ A wj z` � D 0 � �d Fireplace ..................................................................................Approximate Cost ........ .................................................... Definitive Plan Approved by Planning Board ________________________________19________, Area .3.6 p 'Q�' : 1•.,.... Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH Tfr�1 �u 3t�� 50 3o r� 'v YO t � -1 hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name S Pendergast, Raymond 061 No .... Permit for .....�emodel............ .. ......................... ... ............................................................ .......... ....... Location ..i,7.6..Te.r.n..La.....Centerv. 1.1 .......... .............. ............................................................................... Owner .......... ...................... Type of Construction .......Wo.o.d..Fr.ame............. .... . .. .... ...... ........................... .............. .................................... Plot ............................ Lot ............................... /ecember 20 77 Permit Granted ..... ..................................19 Date of Inspection .................... ...............19 Date Completed ................... ..................19 PERMIT REFUSED .................................. .............................. 19 . .................................... ........ ... ......... ....... . ....................... ........... ................................... Appro ......... ............ ....... ................ 19 ............................................................................... ................................................................................ TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Z:L Parcel a171 d Permit# AJ T9 Health Division Date Issued [/2,-hd" 9 Conservation Division Fee s": 4'D Tax Collector Treasurer IAA Planning Dept. Date Definitive Plan Approved by Planning Board t"" Historic-OKH Preservation/Hyannis Project Street Address Village J V2 .Owner J�L/oI/ 0 /Z- S 7� Address Telephone 'Permit Request l�/�� .� �� G—��J Y"o,�oF_- Squaretfeet: 1st floor: existing proposed 2nd floor: existing proposed Total new Estimated Project Cost Zoning District Flood Plain Groundwater Overlay 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 1L�� Historic House: ❑Yes ®'IVo On Old King's Highway: ❑Yes ®-P4o Pasement Type: ull ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing r 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 it ❑Electric Cl Other Central Air: ❑Yes 2 No Fireplaces: Existing New Existing wood/coal stove: W es ❑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 BUILDER INFORMATION Name a u� /I/ l2s Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO �SIGNATU � ? r '��— ATE - FOR�OFFICIAL USE ONLY , np PERMIT NO. n DATE ISSUED - MAP/PARCEL NO. ' ADDRESS VILLAGE r OWNER DATE OF INSPECTION: FOUNDATION ` FRAME INSULATION , FIREPLACE ELECTRICAL: ROUGH FINAL , PLUMBING: ROUGH FINAL GAS: ROUGH FINAL - FINAL BUILDING DATE CLOSED OUT , ASSOCIATION PLAN NO. k 1-- r T • / - / ■ . ' • • • . 1 '1 .. A ralll•AI w. • • 1 . 11 • :1111• . ' . ... 1 � . 1 '1 .. +I u 1 1 1 NNE OWN Ai ig M (j, I 1 / 1 1 �• 1 • 1 1 • �/ .� 1 •' 1 / 1P . 11 . • . •1• •) ' JI 1 I 1 M 1 •I 1 1 11 :�1 I . I . 1 • • 1 •'• •• '1 •• IIU�11 wl. . 1 .• -L •I 11 1 : I 1 I 1 1 I 1 I 0...//...... I u 1 1 1 1 1 1 1 1 I �� i • • • 1 bl• �I ul 11 �J •i r r ru r 1 r r r . r 'JI 11 ' lul 1 1 n it . i + armitAlcense Munding Department city or to"U: ULIcen-rin Board ■ OMce ■ responseE3Heg&Dep ■ • contse person: <...--.- Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", an employee is defined as every person in the service of another under any comr-z. of hire, express or implied, oral or.written. individual, partnership, association, corporation or other legal entity, or any two or more of fined as an , employer is de trot, p rslup � Or the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver 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 m the grounds or building appurtenant ttiereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions 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 contacting authority. OWN Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and supplying company names,address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for capon of insurance coverage. Also be sure to sign and date the affidavit.. The affidavit should be returned to the city or town that the application for the pemi t or license is being requested,not the Department of Industrial Accidests. Should you have any questions regarding the"law"or if you are required to obtain a workers' c ompensatioh policy,please call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom P ea f the affidavit for you to fill out in the event the Office of has to contact you regarding the applicant. be sure to fill in the pejmit/licease number which wM be used as a reference mimber. The affidavits may be retained io the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a caEL The Department's address,telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents Office of lavesd0adons 600 Washington Street • Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 eat 406, 409 or 375 9BA g Department of Health Safety and Environmental Services Building Division • 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Cressen Fax:. 508-790-6230 Building'Conunission e Permit no. Date AFFIDAVIT SOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to ay pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. Type of Work: O' Estimated Cost Address of Work: Z . / ��' I Owner's Name: 4 Date of Application: /�'�"�' 3 I hereby certify that: Registration is not required for the following reason(s): Work excluded by law E]Job Under$1,000 Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED ` CONTRACTORS FOR APPLICABLE HOME MIPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. Date Contractor Name Registration No. Date _ Owner's Nific q:fo=s:Affidav Eb rwd Office: 508-962-4038 mph Crosser. Fax: 508-790- O Building Corr., H03lEOtiVNM LICENSE F.XEMMON C� G� Muse Print DATE JOB LOCATION: / 7j, l sores vtiiage 'HOMEOWNS home phoar A mom phone s CiJ MEET MAWG ADDRESS: l°2/O cr---T�itoyxa State sip coat the ctareat exemption for was extended to inchWe dweltiatn of six traits or less and to allow,bomtm M=to engage as individual for hire who does not possess a license,.nmvlaec that the mumer n=2sSnt+t�rviS DEI IIYlIiON OFHOMEOWKM persons)who owns a patrd of land as which hdshe resides or iasmds to aside,on whirl:th=is,or is iateaded to be,a one artvra-family dwelnn&waded or detached snvcmres accessory to such use radlar firm smxmrcL A petaon who coats==room than oat htt=is a two-year period shall not be cansiderd a hotacowner. Such"homeoxraet'sbail submit to the Big afficid an a form acceptable to the Building official,that ed tmder The huff dinO (Section I09.1.I) _ • o tmdetsigti�"SotIIeowaer' �re p=sffiility for cc=;jff acts with the State Building Code Tad otherappiicabk codes,bylaws,rules andrepladons. .he undersigned"vomeamce certifies that helshe uad=Muds the Town of Barnstable Building Department minienim itispee ion procedures and Izgairements and that helshe will comply with said " prvcccitmcs and r ettzs. - Si ofHomzoe Approval cf BtW q 01$aal Note: Three-family dwellings containing 33,000 cubic feet or larger will be required to comniv with the State Building Code Section 127.0 Cgns=cd=Cosize L ; HOMEOWNER'S E=MP ON stroll be tzemat from fie Code statesh=t "Any h=xotvRa perftmtria8 wade forvWch a bud&g�tu Provisions of this sccdM(Secdoa l c9.1.1- g of Ste=$;t�dd that if the homeowner engages a F=313(s)fotture m do scads woti�tsatstteh Homeoemer e; am zssm=S ttm responsibilities of a supcvisor(see Many ttamennels vA0 toe this°zcmptioA This lark of awaaness often resuits in Appendix Q.RWes&Regtiorsz farLtxnsfn8 Consazu:iou Supervisors.Sermoz• oarBoard casmot Leta against the serious problems.pz=Wady whey the homeowner hirt=uaiicensed porous. In that cases Pm as itwouid with a licensed Supervisor. The homrownes ardD9 as Supervisor is Witmarriy responsible. uafiansed person biliti=num micics z��as part of the Fmmir To— shatshe h�wnes is fully aware afhtslherresponsi nsibilifcs of a Supervisor. On the fast page of this issue's appficatiott thatthe homeowrrcrcrrdfy thathvihe undessraads the zoosuch a formlcerditc=on foruse in your commrurrty- a form cnt=dy used by severs!towns- You may care to amend and adopt Q:fORRlS:E.1'E'tirll'N i *��0 0� pFIRE rp� Town of BarnstablePermtt# Expires 6 m nihsfrom issue.date Regulatory Services Fee * HARNASTAELK y� 039. ��$ Thomas F.Geiler,.Directer arED MA,t h BuiIding Division Tom Perry, CBO, Building Commissioner �1�Ihlag - 200 Main'Street, Hyannis, MA 0260.1 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number _2�2.. 617 OO v r; Property Address�7 cm) LN residential Value of Wort. Mini um fee of$25.00 for work under$6000.00 `Owner's Name&Address I C ! �c /lJ ' ' e 9;17/1 Contractor's Name. .-Telephone Numberz ��'��� /IN I Ionic Improvement Contractor License#(if applicable) 3 �- Cons ruction Supervisor's License#(if applicable) T t� Workman's Compensation Insurance Check one: . ❑ 1 am a sole proprietor ❑A am the Homeowner X-PRESS PERMIT I have Worker's Compensation Insurance nJ r /Insurance Company Name Neu) 7h/y1/�5�j re -�-— OCTOGT �. � 2000 6- (�/J. Workman's Comp. Policy# �C � TOWN OF BARNSTABLE Copy of Insurance Compliance Certificate must be on file. Permit Request(creek box) ❑ Re-roof(stripping old shingles)-All construction debris will be taken to ❑ Re-roof(not stripping. Going over.existing layers of roof) 7Replacemen side 11,31 a-� Windo s/doors/sliders.U-Value (maximum .44) *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 is required. f, SIGNATURE:y���= -� `'�?.'.�-1?F1LFS\PORMS16uilding permit fomislEXPRESS.doe F Revised 100608 D Massachusetts- Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License License: CS 94607 Restricted to: 00 WAYNE F KEITH. ; 35 SOUNDVIEW AVE k CHATHAM,MA 02633 iy i� Expiration: 10/6I2011 Commissioner Tr#: 4362 a License or registration valid for individul use only Office of consumer Affairs&Business Regulation before the expiration date. If found return to: HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation Registration:.. `157610 10 Park Plaza-Suite 5170 Expiration. 11N22J2011 Tr# 288775 Boston,MA 0211- TyPe SBA SOUNDVIEW CONSTRUCTION Wayne KEITH 35 SOUNDVIEW AVE L�D W.CHATHAM,MA 02669.;` Undersecretary IN o valid 'ithout signature r / l The Commonwealth.of 3lassaclittsetts Department of Industrial Accidents - 0 ce of Investigations 600 Washington Street Boston, IV14 02111 www.mass.gov/dia `Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Please Print Legibly Applicant Information y� Name(Business/organization/Individual):_'Ll v Address: City/State/Zip: G%N` - 3 5 3 y Phone #: F20 an7s , ck the appropriate b Type of project(required) v m a 4. I am a general contractor and I 6 �ecdons truction plopart time).* have hired the sub-contractors elin m ar partner- listed on the attached sheet. .' g - - These sub=contractors have g. ❑Demolition ship and have no employees em to ees and have workers' working for me in any capacity. P y 9. ❑Building addition comp.insurance. [No workers' comp.insurance 10.❑Electrical repairs or.additions required.] 5: ❑ We are a corporation and its officers have exercised their l l.❑Plumbing repairs or additions. 3.❑ I am a homeowner doing all work right'of exem tion per MGL myself.[No workers' comp. p 12.❑Roof repairs c. 152,§1(4),and we have no 13.❑Other . insurance required.]# employees: [No workers' comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. , aff avit t Homeowners who submit this affidavit indicating they n doing sh owing work and then o the ire outside sub- contractors and state whethereor notrdthose,enti indicating es have. $Contractors that check this box must attached.an additional employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. g workers'compensation insurance for my employees. Below is the policy and job site I am an employer that is providin information. , Insurance Company Name: 3 Expiration Dater 3 C' Policy#or Self-ins.Lic..#: l l `"� CitylState/Zip:�N�� ^��i� �1�• �r '3� Job Site Address: _1_(!crN by Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). ition of criminal penalties of a .Failure to secure coverage as required under Section 25A'of MGL c. 152 can i e the form of.ad to the os 1 WORK ORDER and a fine fine up to$1,500.00 and/or one-year imprisonment,as well as civil penal 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 under the pains and penalties of perjury that the information provided above is true and correct. Date: d Signature: Z� Phone#: . FDy. Do not write in this area, to be completed by city or town official 9 Permit/License# rity (circle one): alth 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector Phone#: Contact Person: rp aISSUE DATE 71, �� 43-04=2009 sa:a-x'sTHIS CERTIFICATE IS ISSUED AS A MATTER OF INFOR�4ATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED HY THE POLICIES 8EI OR'. MARK T VOKEY INSURANCE AGENCY COMPANIES AFFORDING COVERAGE PO BOX 1247 WEST CHATHAIvi MA 02669-1247 COMPANY A HARTFORD UNDERWRITERS INSURANCE CO LI:TTFR INSURED COMPANY B KEITH,WAYNEF DBA SOUTHVIEW CONSTRUCTION 35 SOUNDVIEW AVE coMlpnr C Lsr;ER CHATHAM MA 02633 LETERCOMPANY . D _ LETTER 5��.y s cbi3- x cscda =mod ..� COMPANY E S*�.�Ls�s acraFYa3 # VIP i Rg ioi �r�x�a � ?�a�?uL� s` s ue ttTTER ._ ,�,- TH1S 1S TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN 1 SS LIED TO THE INSURED NAMED ABOVE FOR THE'POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,17MM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERT[FICATF MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREI'N IS SUBILCT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SLICH POLICIES.LIMITS SHOVtN MAY HAVE BEEN RGDUCED BY PA1D CLAIMS CO TYPEOFINSURANCE POLICYN11NIBER POLICY POLICY LIMITS LTR EFFEC(TVE DATE EXPIRATION DATE (MMIDD/YY) (MMt(DDfYYI GEN [RALAGGREGAT@ $ ��GI1ENER.aL LIABILITY pRODucn-coMwoP Acc. 0 COMMERCIALGENEP.ALU.OEILITY PERSONAL&ADV.L*lJURY :1 0 CLAIMS."LADE Ci OCCUR. EACH OCCURRENCE $ 0 OWNER'S&CONTRACTOR'S PROT. TIRE DAt�1:\GL(Any Ulu I'acl 5 MID.E\PENSE tnuy oIa perso:I $ COMEINED SINGLEUNIIT ffA''11UTONIDBILE LIABILITY 1.1 ANY AUTO - BODILY INJURY $ 0 AILOwwcO;'vTOS 0 SCHEDU•[SDALTCS BODILY INJURY S 0 HIRED AUTOS (Per Aeeidcul) 0 NONOWIEDAUTO ��II PROPERTY D:\M1AOC I 0 QIA.Vi3rt LIABILITY 0 EXTCBIL[TY LACHOCCURRENCE S FORM AGGREGATE• S AN UNI3RELLA FORM? • STAMORY LIMITS X EACHAcaDENT $ID0,000 'SCOHTPENSATIONAND TBD 02-26-2009 02-26-2010DISLASE-FDUCYLIMITSEASE-F�\CHE•�lPlAl'EE $100,000 YER'S LIABILITY THESOLE PRO PRIETORIPARTNER(S)ARE INCLUDED EXCLUDED X DESCRIPTION OF OPERATIONSILOCATIONS/tNEHICLMPECIAL ITEMS THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE OTHER D NUMNAMEB ABOVE FOR THE POLICY PERIOD INDICATED.NOTWETHSTANDING ANY REQUIRGVIENT,TERM OR CONDITION Of ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO TERMHICH S, CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HIbRE9N IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS THIS REPLACES MNt PRIOR CERTIFICATE VSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE - G'KCELI ATi 'N :> FiRIFII��EEFIOLx� . SHOULD ANY OFTHE ABOVE DEcC0.1tlED POLICIES DE CANCELLED BE FORfi THE EXPIRATION DATE THEREOF,THE IWUING COMPANY WILL MEAVOR TO MIA IL THDAT-HOR•IE SERVICES INC tO DAYS11TtMM-4NOTICETO THE CERTIFICATE HOLDERNAN•IEDTO THE LEFT, 269(I CUMBET\'LAND PARKWAY BUT FAJ[AIRETONIAILSLO(NOTICE SHALL IMPOSEN00RUGATION OR SUITE.I� LIABILITY OFANY KIND UPON THE COMPANY,ITS AGENTS OR REPRESENTATIVES ATLANTA GA 30139 ALmwluuD REParssNrenl•E RKMU14 64STM_07vLER HOME SERVICES October 5, 2009 Barnstable Building Dept. The following is an approved installer for The Home Depot: Wayne Keith of Soundview Construction CS License# 94607 and HIC Registration# 157610. Any questions please contact either Mike Bedard our permitting manager 508-962-6942 or me 508-713-4105. Sincerely, Russel J hnston Install on Manager New England Region THD At-Home Services, Inc. 345 A Greenwood Street•Worcester, MA 01067 508-756-6686•Fax 508-756-8823 9 Toll Free 800-657-5182 Boom of swowmas and smoaw* "ONE wwvomff .`M Ems= 8l MI0 Ce+td Typo: S� The Home Depot S�tveOe DARREN DEMERS 3200 0088 GALLEMA PKWY 020 ATt AWA.GA WM A � Licoose or reg value for �Y before the expiration daft. 11'tomd*s" ¢ Board of BYijdiag Reptatioa+and Sts°W* One Asbburtoo Place Rm 1301 Boston,Mm.02108 i .. ..dot v-*Nd J ' V et r SEP-16-2009 12:08 HOME DEPOT HYANNIS P.001, HOME IMPROVEMENT C()NTRACT -. PLEASE-READ T'VIS J �•yy Sold,Furnished andlnsmtled by: tJ ..,-..THI)At liome:Services;Inc: Braneh Name-Bo Kos; Date: Jf :. d/.b/a-MieHome DepotAt]Home Services KA 0.1607- Branch.Num : 345ACmoenwood5trret.lJnit•2;Worcester; _ .TollFree.(800)657-5182;-Fax(508)756-8823 QNortii 33 Sonth 31 F ]I)#'75-2698460;ME Lie#C o2439 3tI Coat.I ic4 i 6427 CT AT#,56§522;:MA'$omc niprovomeiit.Co - n6=.6i Reg:#126893 _ . Instalbttion•Addre w p" ��1+ -+� -a � Cry Lrp. .. A� TL/� •- Parcba 9eirt6a:u„ ~' Work Phone: Home iPhone Ceu Phone �`� Home:Address., •:;:.... ... (rfditlereutf<om.Tnmtllafloa'Addzrss}' - Mate• Zip City E-man ddxess'(te,receive•project commmucanons and'T4ome laepotiipdaxes�: Q PDO-NOT`wisli to.jeeeive'any mazlcetiagemails'fYom ThC Homc Depot" _ ... Pro'cctTriforntatia ni.UndCrsiSncd'(:Custome c");'the owners,of the,pigpertyloctited af.the:aAove installation address,'sinia to buy, and At-Homo Services,Inc.( The Home-Depot") -o furnish;*deliver•and.airange for the installation("Installatiton").of all:matciials•descrn wd•on:the below and.on the refereneed:Spec..Sbeet(4j:a11.of-which:=.uicotporated;into. this.:Contract by this reference,:alou&.*' b Sny..spplicablc:.Swte,.Supplement:atid Payment'Sutntnacy attached zreto sud any:Chsnge.Order;(copCetiivctY, Job W..(t wo W'Rt .odacts S 'c Shcc .d pe Pro e4 Amount Roofing: Siding Wi�xluws b%sulddon b: 6 titiutrerFl.COvets. ttry, :i Rooting,, Siding Wirtdaws - Insulation.• .�, QC,utters/Covers.Q7 ratty Doom,fl $ oofiitg. Siding • ;W"und'ows Insulation .. "$ [IGutters I Covets•'E]Fntry Doors Q Roofiog $jding' Windows Insulation : $ j]Cmttin' Covers [�Eotryx?oors _..- Miininu=259/oDq sibofContiadAmount due'upomesecntionofthiscontraCx::- -Total'Cootrad-Amount' $ ' Name:p,a timen a ay4wt deposit more than one-third of the Contract Amount. Cu..-tomci,agrees>t14 d,-intniediately.upon completion.of the.work"for'eacli;Psoduci;;Customer,will•.ciiccutc�3=Completion�Certificate :(ono.for eaeli Ptofi ct as done'd.by an;in'divjd W Spec:Sheet}and.pay any balance due. As applicable,each Customer under.this Contract a Ccs to h jointly and"" eraljy obligated and.liahle hereunder ;. I he Frorne Depot re serves the'zight to issue.a Change Order'or terminate the:Contcad oc'any.utci�lriduxl=Products)included herein;at ils discretion;if,The Home.ihpot or its authorized servimprovider determines that"it cannot.perform its obligations-due to.a structural ,,problem;with-the Ili me,.eavirotm enta)bz4rds.ssrch.as o(d asbestos•or leadcpaint,other safety.concerns,,pricing errors or because work-'req iredto coi apletZtliejob watinot-inetudcdm tbp:Cotttract PavmcnE Summar ''The 1?aymcnt Stimmaty# (- included as.pirt•-of-'this Contract,sets'forth the coral CotitrauK'amrn;ntsni l-paymcnfs`requiied-f&'tkib'deposits'and 'al 'yments liy Pi'oditcf{as applicable). - NOTICE TO,CUSTO)�M_X You are eniiUed'to se coAopietely filled-in copy of Ehc`Contract.at the;tini'e you sign.Do not si r a'Completion CertitFcute(note: there is one Completion Certificate for each lit+ted Product as defimeil`by individaal Spec'Sheds)"before work`.oa'tliat Product is complete: in the event.of ter nination of this Contract;Customer'agrccs to pay The Home-Depot the costs of materials,labor,expenses and services provi led ty TAc Home Depot,or Authorized Service Provider through the date oUtermiustion,plus any other amounts set forth I a this Agreement or allowed under applicable.law. THE HOME DEPOT MAY-WITHHOLD AMOUNTS OWED TO TUE.UGME DEPOT FROM TIIE`DEPOSIT PAYMENT OR-OTHER PAYMENTS MADE, WITHOUT LIMITING THE I OW DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Acceptance and A•ithorization: Customer-agrms and understands that this Agreement is the entire agreement between Customer and The-Home Dep tt with regard to the Products and Installation services and supemedes.all.prior discussions and agreements,either Orel or written,rcial ing.to said Products and Installation.This Agreement cannot be assigned or amended except by a.writing signed by Customer and 7n z-Home Depot.Customer acknowledges and agrees•that Customer has read,undeistands,voluntarily accepts the terms of and.has rec rived a copy of this Agreement -. A by Sobm' ed Cut s b c Date Sales Cos itant's' ' atwc 4 r z e Tel o. 9 omer's Sigiatu e, Date Sates Consultant License No. (as applicable) CANCELLATIUl`: CUSTOMER L MAY CANCEL THIS- AGREEMENT W+THOUT PENALTY OR-.OBLIGATION BY DELfVER]NG wRrmN NOTICE TO THE HOME DEPOT BY MM NIGHT ON THE:THIRD .BUSINESS . DAY AFTER•91'NING THUS .AGREEMENT• THE STATE: 'SUPPI EMENT ATTACHED -HERETO CONTAINS A FORM TO. USE . OF ONE IS SPECIFIGALLY`tt I .PRESCRIBED -BY LAW IN . i J,CUSTOIVIF.I ssi.4,TE. NOTICE:ADI IlIONAL TERMS AND CONDITIONS A STATED ON THE REVERSE SME:AND ARE PART OF THIS CONTRACT RE .. -crt ..- -• -....., _:.. -t�tYOBo w-•Cuomre: PInk_Satesconsultant :. ..,_... .. _t a.. .w , ry,3,.. a. P...a r. s 3+Y .dam ,.�( , r.� t -� 3�.31�,< �..3�..,,...fb ,..,3i ..,., ....r, E :,x .3... ,n , ,, ....:i'.� .. e,., r i r ,,.,,.•.. x..,. r x, �.::n rtx � .. I ,... EE (,�.. S .•., �.{ j,� .{ ,.. .a.:..�{ , h. I ...:. 3 ,r; ,..- .,;.. ;,,1N 4+,.:, 3,i.. 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