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HomeMy WebLinkAbout0050 HIGHLAND AVENUE $D thyth.�tTl� A-✓E Application number ....................................... Fee.............�... . .............. ............ ............ MASS Building Inspectors Initials......... OCT 24 2018 Date Issued........... ....... ................. 0.TOIAIN,O� 6AHN8_1ABLF Map/Parcel........ .0...............I....................... TOWN OF BARNSTABtE' ­01 EXPEDITED PERMIT APPLICATION: ROOF/SIDINGIWINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION 'PROPERTY INFORMATION Address of Project: NUMBER -,VILLAGE Owner's Name: Phone Number/:� Email Address: Cell Phone Number .4 o Project cost$ C Check one Residential Commercial OWNER'S AUTHORIZATION_ As owner of the'above-property I hereby authi6rize_ to make application for a building permit in accordance with 76 CNM Owner Signature: Date: TYPE OF WORK 21 Siding i i��i�nildolwl s (no header change) Insulation/Weatherization 1 4 ED Doors(no header change)*# Commercial Doors require an inspector's review Roof(not applying more than I layer of shingles) Construction Debris will be going to CONTRACTOR'S INFORMATION Contractor's name laf Home Improvement Contractors Registration (if applicable) # (attach copy) Construction Supervisor's License# (attach copy) E19 / Email of Contractor & ' 11P.0MV- ,97- �g,0141, CG11 Phone number 6 9)7401_ ALL PROPERTIES THAT HAVE STRUCTURd OVER 75 YEARS OLDOR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER..................................................... *For Tents Only* Date Tent(s) will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X 1, X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit enon-profit event Check one: Food served Yes No' Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s)of each tent If food is being served at your event please,obtain a Health Department approval between the hours of 8:00am -9:30 am or 3:30 pm-4:30pm. Commercial.events may require Fire Department approval *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION ' Homeowner's Name: Telephone Number Cell or Work number I understand my-responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures, specific inspections and documentation required by 780 CMR and the Town of Barnstable: - i Signature Date APPLICANT'S SIGNATURE - Signature Date All permit applications are subject to a building official's approval prior to issuance. 1 he commonwealth of massacitusetts Department of Industrial Accidents' Office of Investigations 600 Washington Street Boston,MA 02111 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers" Applicant Information Please Print LeEibly " Name(Business/Organization/Individual):—I?A 4jZ ' Z ,-IA%�/ Address: 1,.3aA /yZ City/State/Zip: CGluif Phone#: 3WD 'y1� Are you an employer?Check the'appropriate box:' E Type of project(required): y. , 1.❑ I am a employer with 4. I am a general contractor and I * have hired the sub-contractors '6. []New construction ployees(full and/or part-time). , , t l , 2. I am a sole proprietor or partner-* listed on the attached sheet 7.'❑Remodeling'' These sub-coritractois have• ' ship and have no employees � S. � Demolition y , working for me in any capacity. _ - employees and have workers' [No workers'comp.insurance comp.insurance.t 9. Building addition ,5. We are a corporation and its• 10.❑ Electrical pairs or additions required.] r rP k. 3.❑ I am a homeowner doing all work , officers have exercised their 1 LQ P ing repairs or additions myself o workers'comp. right of exemption per MGL , , Y P 12.[0Roof repairs insurance required.]t c. 152,§1(4),and,we have no t i employees. [No workers',..'. 13:171 Other" comp.insurance required.] + "Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. ,. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 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 and job site s information. C. ' ' Insurance Company Name: - _ , Policy#or Self-ins.Lic.#: Expiration Date:F Job Site Address: . - . r. .;; .r^ ° ,: - - ; . , . • -... � .-„ i. - City/State/Zip: a 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, r 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 and r the pains andpenalties ofperjury that the information provided above is true and correct .. Si afore: � Date _l M _.' _ , __.._ _ ; � •- �:. Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone M Information 'and •Instructions , r Massachusetts General Laws chapter 152 requires all employers to provide workers compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the`service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or,the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do•maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage#required. ' Additicnally,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." t' Applicants ' Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you`are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. - - - City or Town Officials , Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please:be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple 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 provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new'affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related 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. I ' • . - " ' • - The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 600 Washington Street Boston,MA 02111 -" Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia - c. Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Const`,,g6t,I bpy,rvisor CS-103429 Tres 09/30/2019 h PAUL Z ROMA P.O.BOX 142 COTUIT MA 02635 N_� ` ' - 1. 4' o I N 61 w n ° N W O ll/'LI C07 Commissioner CL M 3 ` rL O N N ,O .N C o , ;, L ° � � i7m�1'.^mitt??-rneiartrmasv.. .�,..rnr+.a .,m-. ...._,,..,•- --- /h .. „��• N O� E `� m E GG� O ' a4,jac/LC �y.� y ca V CB O%%L%YLd%'/•C(JCCL L / (JC[•LU y ,p C > N Q G N 7 i office of Consumer Affairs&Business Regulation`U(�L i > > •w°-, O .r c ,m•m n '.y'�., ; n HOME IMPROVEMENT CONTRACTOR y °o `p ° ' I ' TYPE: Individual o;° °:a m '0 > ° w`:»' I :Registration Expiration = N in3 c `o CO 147262 06/22/2019 •.w. j u m L= ° o axi c (o.•p I ; PAUL Z.ROMA: IM O CD N V U IC O PAUL Z. ROMA _,: �1Z CG��—' 29 BAYBERRY LANE, i _ Ca COTUIT;MA 02635 Undersecretary, w « a m - W. i - . , l 0 pF Tt1E Tp� Town of Barnstable *Iserinit#� 6 Q- l- � ti O� Expires 6 months from issue date Regulatory Services Fee — BMWSrnBLE, y tKnss. Thomas F.Geiler,Director ,DIED MA'I"A Building Division Tom Perry,CBO, Building Commissioner.' 200 Main Street,Hyannis,MA 02601 JAN 14 20�0 www.town.bamstable.ma.us Office: 508-862-4038 ® "N®F BARNWAMS30 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address 11 G�1 avid �6!Q C O+u v , R sidential Value of Work Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address , f t�iDd1 "Pfl�-'� o_lt� P� ( U Contractor's Name Telephone Number 5 C' 14 Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicableL-- l 0 372 9 ❑Workman's Compensation Insurance Ch . I=aI am a sole proprietor ❑ lam the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) - [/RRe-roof(stripping old shingles) All construction debris will be taken to7k ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum.44)#of windows *Where required: Issuance of this permit'does not exempt compliance with other town department regulations,i.e.Historic,Conservation,'etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required SIGNATURE: Q:\WPFILES\FORMS\buil ng permit f s\EXPRESS.doc Revised 090809 The Commonwealth of Massachusetts Department of Industrial Accidents !' Office of-Investigations I' 600 Washington Street s `! Boston, MA 02111 wrvw.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information A Please Print Legibly Name (Business/Organization/Individual): /Z Address: 5�? City/Stal Phone #: Are you an employer? Check the appropriate box: Type of project(required): 1.❑��l am employer with 4. ❑ I am a general contractor and I 6 ❑New construction ployees (full and/or part-time).* have hired the sub-contractors 2. am a sole proprietor or partner-' listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition workingfor me in an capacity. employees and have workers' Y P Y• 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑-I am a homeowner doing all work officers have exercised their l l.❑Pltt bing repairs or additions myself [No workers' comp. right of exemption per MGL 12. Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 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.the policy andjob site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL- c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification, I do hereby certify tinder t pains and penalties of perjury that the information provided above is true and correct. Si nature: _ Date: Phone#: �G� �G Official use only. Do,not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority (circle one): L Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: } Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'.compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire; express or implied, oral or written." An employer is defined as"an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7) states"Neither the conunonwealth 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-contractors)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit sho uld be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial.Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current " applicant should write"all locations in (city or under Job Site Address the policy information(if necessary)and town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. . The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 4-24-07 www.mass.gov/dia E SHE Town of Barnstable Tp� O Regulatory Services 9 anxry i E Thomas F. Geiler,Director 9,�►`� Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Pax: 508-790-6230 Property OwnerMust Complete and Sign This Section If Using A Builder I, as Owner of the subject property hereby authorize >00 eh to act on my behalf, in all matters relative to work u/thorized by this building permit application for. (Address of Job) aiure of Owner Date Prue Name If Property Owner is applying for pen it please complete the' Homeowners License Exemption Form on the reverse side. Q:FORM&O W N E RP E RM IS S I ON R Town of Barnstable, OF ZHE Tp� ., o� Regulatory Services BARN srnsr a Thomas F. Geiler,Director MAss. 9�A 039. a,�� Building Division TEo IA!►�l Tom Perry,Building Commissioner 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 e who does not possess a license provided that the owner acts as to allow homeowners to engage an individual for hire w p � supervisor. DEFINITION OF HOMEOWNER Persons)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 be/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 helshe 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\FOR-MS\bomeexempt.DOC 1 � �Yassachusetts- ®e Board of Building.Re rtment of hlic Safet%: C®n�trra� .io. 1ulations and Standard, License: P rvasor LIcen�e 10342.9 RestrictedRestrictedto: p0 CS PAUL ROIMA P-0.8OX 142 COTUIT, s MA. 02635 . .#nunner Expiration: 9I30/2013 71#. 103429 1 L l k i HIC Registration Complaints Page 1 of 1 The Official Website of the Office of Consumer Affairs&Business Regulation(OCABR) Mass.Gov Consumer Affairs and Business Regulation Home>Consumer> Housing Information> Home Improvement Contractor Program> ...................._.....__...._._._......................_......................................................._..............:............._.........._................_.........._................_........................................_......._._................._.....__.._._.. HIC Registration Complaints Registration# 147262 Name PAUL ROMA City,State,Zip COTUIT,MA,02635 Expiration Date 6/23/2011 Status Current No complaints found for this registrant. You can also view arbitration and Guaranty Fund history. Back To Search ©2010 Commonwealth of Massachusetts http://db.state.ma.us/homeimprovement/licdetails.asp?txtSearchLN=47966 1/14/2010 Town of Barnstable *Permit#-21Z q0 ( g ti0 Expires 6 n or s frg!W date Regulatory Services Fee =G� • enrwsz�at.E, Thomas F. Geiler,Director 'pr%619. a Building Division FD MAC Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION. - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint. Map/parcel Number 0A d a Property Address 5o Hkelk(CLACJI CUAUE Gfoa OAC, esidential Value of Work ��V` .-, Miniritum fee of$25.00 for work undbr$6000.00 Owner's Name&Address—hy un e0beA�o Contractor's Name 5 ,/)(Ade, L-L)lq Telephone Number Home Improvement Contractor License#(if applicable) RMIT [� (7 1 _ _ Workman's Compensation Insurance ' X-PRESS PE . Check one: ❑ I am a sole proprietor MAR ?��9 ❑ . am the Homeowner have Worker's Compensation Insurance TOWN OF BARNSTABLE Insurance Company Name. Mutual R5 , Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side 11/Replaceme �Wdowsdoors/sliders.U-Value (maximum.44) -S�t.VVI r2, f --5aALe *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 i SIGNATURE: j Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revise020108 i The Commonwealth of Massachusetts Department of Industrial Accidents . Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly �L�� ��UYI�(R_Nai:ne(Business/Organization/individua]): Snv',n i1>I/t/J. Address: tqC( 1 J�.l((!1`��"WJ' e City/State/Zip: �tJ Phone.#: 6C�� Are y an employer? heck ppropriate bog: Type of project(required): 1. I am a employer with . . 4. ❑ I am a general contractor and I V6. New construction employees(full and/or part-time).* have hired the sub-contractors ❑ 2:❑ I am a sole proprietor or partner-' listed.on the attached sheet. 7. .❑Remodeling ship and have no employees These sub-contractors have g•'❑Demolition workingfor me in an capacity. employees and have workers' Y P h'• $ 9. ❑Building addition . [No workers'.-comp.-insurance comp'ms�ce• 10. Electrical airs or additions required.] 5. ❑.We are a corporation and its ❑ rep 3.El I am a homeowner doing all work officers have exercised their 1 LE]Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.)t C. 152,§1(4),and we have no employees. [No workers' .13.0 Other' —616LAY.-5 comp.insurance required.] v *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-conuactors and state whether or not those entities have employees. If the sub-contractors havi�employees,they must provide their workers'comp..policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information.Insurance Company Name:_GE N r`tow p t t T:A5 Policy#or Self ins.Lic. f#1 OO Uq`'l 56� I- Expiration Date: Job Site-Address: vy �t�q, d �,yp City/State/Zip: G+(Xf G 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 crimiriatl 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 maybe forwarded to the Office of Investigations of the DIA for ins overa a verification. I do hereby ce sand penalties of perjury that the information provided above is true and correct Si afore: Date: Phone#. (�� 17 S — 1� �` Official use only. Do not write in this area,to be completed by city or town of City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: fl - :,vs 1- �iIil:�•'3�:��i.'i�i Ti�GL�►977I�I:�1s:[�luls�ul�:U I � T �..- 1261/2008 14:18 Bryden & Sullivan'Insurance Donna Seviour-►Margo 1/2 ACORy. CERTIFICATE OF LIABILITY INSURANCE. OP ID DS O ATE(MbVDD/YYYY) SPRIN-1 12/31/08 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Bryden & Siiliivan Ins Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 88 Falmouth Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Hyannis MA 02601 Phone: 508-775-6060 Fax: 508-790-1414 INSURERS AFFORDING COVERAGE 'NAIC# INSURED INSURER Associated Industries of NA INSURER B: Spprinkle Home Improvement Inc. INSURER C: 189 Barnstable Rd INSURER0: Hyannis MA 02601 INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEENREDUCED BY PAID CLAIMS. INSK POLICY EFFECTIVE POLICY EXPIRATION LTR NSRD TYPE OF INSURANCE POLICY NUMBER DATE(MMNO/YY) DATE(MM/DD/YY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY PREMISES Ea occurence s CLAMS MADE - OCCUR - - MEO EXP(Airy one person) S. PERSONAL&ADV INJURY s GENERAL AGGREGATE S GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO s 17 POLICY JE4 LOC AUTOMOBILE LIABILITY s COMBINED SINGLE OMIT s ANYAUTO - (Ea accident) ALL OWNED AUTOS - BODILY INJURY S .. SCHEDULED AUTOS - (Per person) HIRED AUTOS - - BODILYINJURY S NON-OWNED AUTOS (Per accltlent) PROPERTYDAMAGE - S (Per accident) GARAGE LIABILITY AUTO ONLY-EAACCIOENT s ANYAUTO • OTHER THANEAACC S AUTOONLY: _ -AGG s EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE It I OCCUR CLAIMS MADE - AGGREGATE It s DEDUCTIBLE RETENTION s - - s WORKERS COMPENSATION AND WC STATLL OTH- TORYLUNTS ER EMPLOYERS'LIABIUTY A ANY PROARIETOR/PARTNER/EXECUTNE - AWC7004943012009 a 01/01/09 01/01/10 E.L.EACH ACCIDENT s 500000 OFFICER/MEM8ER EXCLUDED? - E.L.DISEASE-EA EMPLOYEE s 500000 .I yes,descnbe under _ - SPECIALPROVISIONSbelow E.L.DISEAASE-POLICYLIMT s 500000 OTHER - DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDEO BY ENDORSEMENT/SPECIAL PROVISIOdS - CERTIFICATE HOLDER CANCELLATION . SpRNmo SHOULD ANY OF THE ABOVE DESCRIBED POLICIES Be CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN Sprinkle Home Improvement, Inc NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Fax #508-775-1350 -IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Margo Mack 199 Barnstable Rd. REPRESENTATIVES. Hyannis MA 02601 AUTHORIZED REPRESENTATIVE lKelley A.Sullivan ACORD 25(2001108) 0 ACORD CORPORATION 1988 r ti%+ 't ru .u.%atlt tr'.arr , r! :,pr r r--r;✓a 1io iid of I34iildmi Regulations nud Sl uiidtu dz p Construction Sup"ervisor:License 5: Li'c'ense:. CS: 6643 Exparatron: 1'018/2009 Tr#` 94?7 Rest'ri'ctior1: 00. BRAU:K aPRi'NKL`F 190.LOTH RORS'LANE W BA'RNSTABILE,M'A 02668 C<iirunnsioa'ca t' 0.0 3�;00':0 cf enclosedspace 1A Masonry only :.2`Family:H01tes ! � ` .F:ailu,re to possess a curreiit edaGipnoYt}i`e 1Vlassacti.0 efts S ate Building Code I s.cause or re�o'eation ofsthis 1►cens,e: i ...... _.. . /,•�.:• (i, n: ;>m Jr[2�fs:. r� 1['GYil.r r rt Je:J('ri.�G . Board'of Buildirig R-egulati.ons andEStagd'ards HOME IINPROVEMENT CONTRACTOR Registration: 10375-7 Ex'piratwn 7/9/2010 Tr# 271:033 Type:: PnuaCe Corporation SPf?INKLE HOME IMPROVEMENT, ING. Brad: Sprinkle ,. 199!Barnstab1e Rd: ��-`. : Hyannis MA:02601 Admn`istratoi= License or registration valid for individul use only before the expiration date, If found return to: Board of Building Regulations and Standards One Ashburton Place Rm 1301 Boston,.Ma.02108 3 Not valid wit out sig ture zTo�ti Town of Barn-stable Regulatory Services �uxxs Thomas F.Geiler,Director �a��� Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.b arnstab le.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete:and Si' .. T n's Section If Using A Builder I, Mae= Aow,�C) ,as Owner of the subject property hereby authorize JLUOact on my behalf, in all-Rmatters relative.to.Viork-authorized by this building permit application for:. _ 5U R C k,b-- i + .(Address of Job ignature of Owner Date Pyrnt Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. fl•F(1RKA.C•f1WNFRPF.RMI.CC1(1N