HomeMy WebLinkAbout0177 LITTLE RIVER ROAD i
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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Mao Parcel M41 Application
Health Division Date Issued
Conservation Division Application F
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation/ Hyannis
Project Street Address �� � C
Village LO U' ,
Owner N 6 t D61 6'r ZO fn.1�) Address
Telephone
L 17 ✓ 6 y
Permit Request
Square feet: 1 st floor: existing 9TO proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Grounlwater
1 O verlay
Project ValuationConstruction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family 3 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
I nr]
Basement Finished Area(sq.ft.) — Basement Unfinished Area-(sq.ft):/ Irk In '�
N1 n) IIINumber of Baths: Full: existing new Half: e.1 ,( �c� new
TT ,,,�
Number of Bedrooms: 3 existing new .�-- B y �V f
Total Room Count (not including baths): existing new First Floor`Room groj t 3
Heat Type and Fuel: ❑ Gas b Oil ❑ Electric ❑Other
Central Air: ❑Yes ❑ No Fireplaces: Existing VNew Existing wo7eAsting
I stove: ❑Yes a o
Detached garage: ❑ existing ❑ new size Pool: ❑ existing ❑ new size _ Barn: ❑ new size_
9 g g
Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other:
Zoning Board of Appeals A horization ❑ Appeal # Recorded ❑
Commercial ❑Yes No If yes, site plan review#
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name �C p
Tele hone Numberhy
Address f 1 / License#
Home Improvement Contractor# �6✓
Email Worker's Compensation # f!/a"5,67JY Z064
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO j
SIGNATURE DATE `S
t
a
FOR OFFICIAL USE ONLY
v
APPLICATION #
DATE ISSUED
MAP/ PARCEL NO.
,T
r ADDRESS VILLAGE
OWNER.
DATE OF INSPECTION:
1., FOUNDATION
r FRAME co3/2� l4
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
! PLUMBING: ROUGH FINAL
CAS: ROUGH FINAL
FINAL BUILDING
uw
DATE CLOSED OUT
t
ASSOCIATION PLAN NO. ,
the Co�irrrorrftvealthi otf161assat lirisetts'
Depcartime d ofrnrlsaetria1Accrde_7ats
n - r Offare offTmwfigations
{r 600 Washbigion,street
Roston,M4 O'2111
turvtr:masmgov/din
Warkeis' Cu mpensation Insurance Affidavit:Bmldei-siCnntradGrs/EIectricianslPlumbers
Applicant Infar matinu Please 'bI
Name anim ionrindid&m1-
Address:
• eitYf*.ter _ � 1� - . Ph 70oa�� � J � �4 .a�7
Are . , an employer?Check the appropriate box: Type of project(requireq:
I.
I am a general contractor and I
I am a employer with.. �� ❑ - 6_ New construction, . .
employees(full andlor part-time).* 'have lured the sub-contractors
2.❑ I am a sole proprietor or partner- li red on.the attached sheet:. 7'_ ❑Remodeling
slip and have no.employees. These sub-contractors have g. ❑Demolition
wadring for me'many capacity employees andhave wozlcers'
" p-ibsi ranm comp. 9_ El Building addition,
[No rti-oriaers.'comp.insurance; .
required-] 5.❑ We area corporation and its-' 10❑Electrical repairs or additions
3.❑ F am a homeaum offscers.have eoxerdsed their er rains all wank 11_❑Plumbingrepairs or additions
my self o-workers' - right of exemption per MGL
� '-' c.I52 §1(4kandwe�aveu�a 12_❑Roafrepairs.
insurance regained]f
employees-[No wmkers' .❑other
comp.insurance regu,red_j
•tLay Rn iczntdmt checksbox Pl must also fill crafthe sectioaberawshowing their wozkex'compensation policy iVhaMffdcaL
l ameo,uaers who submit tfsis afiidaiif inxticating tlw_y are doing all'wol and th hire outsidecDutractorsmnst mb=t a new afdaviit indicating sa h '
fC'anttacto,s that ehea thin box m=attached as additional sheet showing the nme of the sub-cemt,wAon and state whether or not those eaddes hive
employees.Ifthesub- -ttactnesbave employees,they=ustpmuide their workers'comp.policy number.
lain ain ersplo}�crr tlerrt isprotzriitrg n�orkers'cQntperrsrrharr i�rsurance for Sri}*eniploynees: BeIvav is�tl�e policy rrr�d jab ait�
it forexadam
Insurance Comipair Name: �
Poll 4k or Self--ins.Uc_�: vat r � ( ! `i V r�
cy �-7 r EjrpiratiouDate:
Job Site Ad ess: l I ) r�l�`r cityl5tate�7.tg:
Attach a Sapp of the-workers'compeasationxpolicp declaration page(shoWM9 the policy number and espii-ation tiate�.
Failure to secure coverage as required under SecEion'?SA of MGL G.•152 can lead to the imposition of criminal penathies of a
fine up to$1,50D 00 and,'or one-year imprisoanier4 as well as cMI penalties,in the form of a STOP WORK ORDERaad.a fine
of up to$250_00 a day against the violator. Be ad-used that a copy of this statement maybe fpswarded to the Office of '
Investigations of the DIA far insurance coverage verification
I do hereby ce&f j,under e 'is a o.fperjuq thatthe informal gn protiried abmv true 4Wjd correct +
SiemAure: Date-
phone ifk
Official use early. Da not a rite in this.area,to be campldead by t:ity Orton n of far L
City-or Tcmu: P'ermitUcense#
Issuing A.utherity(circle One):
1.Board of Health 2.Building Department 3.Clity1rown Clerk 4.Electrical Inspector 5.Plumbing Impecter
6.Other
Contact Person: Phone#:
Tafarmatianx and lastructions n
Massar_husetts General Laws chapter 152 req=s all employers'to provide workers'compensation for their cruplOYEes-
pur.snantto this ,an employee is defined as_"_.evmy person in the service of another under any contract Of hire,
express or jmplied,oral or wiiftenf
An.e1rPIoyer is defined as"air 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 Iegal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or tho occupant of the -
dweIling house of another who employs persons to do maintenance,consiracfion or repair work on such dwelling house
or on the,a grounds or building appzu ten Ahemb shall not becanse of such employment be deemed to be an employer"
MGL chapter 152,§25C(6)also st tes that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a burliness or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7 states`Neither the commonwealth nor airy ofifs political subdivisions shall
enter into any contract for the performance ofpublic work until acceptable evidence of compliancevtith the;ngrance..
en
requiremts of tT:]s chapter hava bee ppi-esented to the contracting a afh oiity-7
Applicants
Please fill out the worker'compensation afffidayit completely,by checking the boxes that apply to your situation.and,if
necessary,supply sub-contractors)nane(s), address(es)and phone nomber(s) along with their cerifficate(s)of
iDs nee. Lfi ited Liability Companies(LLC)or Lfi iced Liability-Partnerships(LLP)with no employees other than the
members or partners,are not required to carry wormers'compensation ice. Bran LLC or LLP does have
employees, a policy is rec t ed- D e advised that this affidavit maybe submitb--�d to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date+he affidavit The affidavit should
be retarned to the city or town that the application for the permit or license is being requested,not the Department of
Trrh,etrla1 Accidents. Should you have any questions regmdiug the law or ifyou are reguired to obtain a workers'
compensation policy,please call the Department at the number 1isI:ed beIow Self-insured companies should enter their
s e1f-m crrran ce license number on the appropriafe line.
City or Town Officials
t
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 went the Office of 7nvesiigaiions has to contact you regarding the applicant
Please be sure to fill in the pemutl Corse munber which wi-Il be used as a reference number. In addition,as applicant
that must submit multiple permitllicense applications in any given year,need only submit one affidavit indicating current
p olicy haf6=ation.(if necessary)and under"Job Site Address"the applicant should write"all locations in ( Y or
town)."A copy of the.affidavit that has been officially stamped or marked by the city or town may b e provided to the
applicant as proof that a valid affidavit is on file for funnre 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
(ie. a dog license or permit to b- m Itwes dz-)said person is NOT required to complete this affidavit
The Of of Investigaii-ons would at to thank you in advance for your cooperation and should you have any questions,
pleasedo not hesitate to give us a call.
The Department's address,telephone and fax m=ber.
'I7�e C-G-MM�aaWcedtb�of Massachust�
Degas tm6nt c&1n-dudza1 Ac(--UentE�
Ofu=of kvegtintio-=
Bostou2 MA 02111
T�1. 617 727-4900 Qmt4Q6 or 1-977 MA 2aAF F
Fax 617-727 7749
Kevised424-07 -MaS.5.90VId
A„
of r y Town of Barnstable -
Re afo t rY Services
' E RiSfNCriRfV• i - - -
xes�$ Richard V.ScaH,Director '
Building Division r
Tomrerrp,BMIdmg CDnmdsdoner
200 Main Street Hpazais,MA 02601
WWW townlanmtable mazes
Office: 508-862-4038 F 508-790-6230
Propeity Owner Must
Complete and Sign This Section
If Using A Builder
DOM A Y1 as Owner of the subject ro
' - � - J P PeXL9•
he�byazxtbol ITR / ,�� V to act on b
in all matters relates to Wok aurtborized by-this bmIding permit aPPlieatron for. . -
lJ,
-(Addmss of Job)
Toolfences and alarms are the responsibil yof the applicant Pools
are not to, be Me i or i ized before fence is installed and aU final "
inspections are peifornied and accepted-.
•
SICM— p of Owner F Signature of AppTirant -T--
P4=Name - Pu=Name
Date .
- Q:FORMS�Wb�RPEB2,9SSID21Poors •
Town.of Barnstable s ..
Regulatory Services
ova r � Richard V.Sea]%Dirmdnr
°+ Bid ng bidd=.
t � a�rasxr� Tom Perry,Bta-Eling Commission=
YEA$ _ M 1a 200 Maim Street, Hya=is,MA 02601
wwvr tmP barnsbbIm m_a__IIS '
Office: 508-862-4038 Fax: 508-790-6230
HOIMWNERrrraNeRR.IO TION
' PfeasePrint
JOB LOCAnObl:
nnmbcr'
'$ONlFA�T2gR
homcphooe# tva3cpiionc#
CURRENT MAII.fiIG ADDRFSS.
ccipl�rn hip code
The can mt exemption for"homeowners"Was extended to include owner-flccnpied dweTlmzs of six 1mits or I=and in aIIoW
homeowners to engage an individual for hirewho does notpossess a license,ptovi ded thatthe owner acts as supervisor_
DEM-g ION OF HOMEOWNER
P erson(s)Who ovens a parcel of land on Which.helshe resides or iniands to reside,on which there is,or is intended to be,a one or two-
famuZy dwelling,affacbed or detarbed strnct m-ms accessory to surh use and/or farm sft ucimss. A person who consimcts more than one
home in a two-year period sball not be cmsi+im-�d.abome -vmcn Such`homeawnee-.shaIl sobmitto ffie Building Official on a farm
acceptable to f3ie Bun1dmg Official,that helshe shall be responsible far all such warkperfo=cd un&erllm bu0din e vomit (Section
109.L 1)
The undersigned`.`hozneovmee'accmaes responsIilitp for compIsaace wdhthe State Building Coda and other applicable codes,
yk andrmg-alatims-
b ws,tales t, - '
,he nadnmgmed`homeowner"cerlffies thathelshe understands the Town ofBamstable Building Dcpartmantmin =inspection
promdnres and requirements andthathelshmWMcomplywith said pmmdnres andregairmaeois.
SigaamrcafHnmcawnc
Appmvdl ofBr@crmg0f5c3at
• Note. Three fly cipmEh s containing 35,000=bie fleet or larger wMbe requi mdin comply wi.ft&o Slats Bulldmg Coda
Sectian f27.0 Cons'(rnction 1..lLAl ML
B:GMXOWNHXIS
The Code stairs that: aAny homeowner performing workfor which a baIldiag pmrmit is requre$shall be exempt
from t$e provisions of this section(Section 109-11-Liceu of contraction Supervisors);provided that if the homeowner
engages a persoa(s)for We to do such work,that such Homeowner shalt act as supervisor."
Many homeowners who use$xis exemption are unaware fiat they are assxming the responsibilities of a supervisor
(see Appendix Q,Rules&Regulations for Dee s ng Construction Supervisors;Section 2.15) This lark of awareness often
results in serious problems,pardcularlywhen fka homwwner hies unlicensed persons. Tn this rasa our Board cannot
proceed agaimst the=xomused person as it would with a licensed Supervisor_ The homeowner acting as Supervisor is
urIB=te responsf-Me.
To eussm-e$tat the homeowner is folly aware of hislher respoasr7 ffities,many commm3ities require,as part of the
permit application, that the homeowner certify that hehhe understands the rmponsi iilides of a Supervisor. On the last:Page
of this issue is a form rn rrently ufaed bp.seperal towns. Yon may=e t amend and adopt such a fo rm/ezrUffi:ation for use in
your camm�usraiy.
Q�R'PFII�S�OEMSIr,,,���p®itfnffist�RFce�c
Revised 06 U 13
sr� A: f4s.�'""} •':• ti : r sf` I,.h��r a4i `Ya k r, 1� 8 Y t i SN Y...�rl S ? I: cF r ;-y..;
7 g7 1 J
W,� f sSr
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Massachusetts De,partme.nt of Public SaQety
� A
j Board of Building R.egulatlons and;Standard,.
ConstructioaSupervisorg
x s'
License:.CS-050234 `,
tY`:.a,
WCHAEL•AELUA.
568 SANTLIT
COTUIT MA 02635,
Expiration \ t
c�' ✓,• I s
Commissioner 07109/201ti = "
4
' oyrvrrcantuca�c a�(�uGJccc�ccaeG�'i Y ,\
Office of CoasumerAlfairs be Busidess,Itcgulition ;
pME IMPROVEMENT CONTRACTOR' p;
egisteatiotn: c,105548 Type:
,
xpiratipnj .Z/t�12016� DBA
VILLA E CRAFT Bl�l jDIN J&RE^RDELING f
I r
t \ t-
Michael Deluga
568 SANTUIT•RD
COTUIT,MA 02635 - `
Under5cc.L�t,ity
t )
License o.,r regi$ttration LYaljd fpr jndmdul use only
before the expiration date. If found return to a F
Office of(consumer Affairs and Business Regulafioii
IO PQrk V14;a Suite 5j:70
Boston,MA 02116
Not Yalid without si ature. • \
f ,
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Employers Insurance Company`s
54 Third Avenue, Burlington, Massachusetts 01803-0970
(800) 876-2765 NCCI NO 40959
POLICY NO. 6145A
1PRIOR NO. 6 ITEM
1. The Insured: Michael Deluga
DBA: Village Craft Building&Remodeling
Mailing address: 568 Santuit Road FEIN:**-***2146
Cotuit, MA 02635
Legal Entity Type: Sole Proprietor .
Other workplaces not shown above:
2. The policy period is from 12/23/2015 to 12/23/2016 12:01 a.m. standard time at the insured's mailing address.
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the
states listed here: MA
B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A.
The limits of liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 100,000 each employee
C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B
D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans.
All information required below is subject to verification and change by audit.
Classifications Premium Basis Rates
Code Estimated Per$100 Estimated
No. Total Annual Of Annual
Remuneration Remuneration Premium
INTEA 355380
INTER SEE CLASS CODE SCHEDU E
Minimum Premium $500 Total Estimated Annual Premium $2,638
GO V GOV Deposit Premium $693
STATE CLASS
MA I 5645 State Assessments/Surcharges
$2,291.00 x 5.7500% $132
This policy, including all endorsements, is hereby countersigned by � 10/20/201.5
Authorized Signature Date
Service Office: Malcolm& Parsons Insurance Agency Inc
54 Third Avenue P 0 Box 527
Burlington MA 01803 Stoughton, MA 02072
WC 00 00 01 A(7-11)
Includes copyrighted material of the National Council on Compensation Insurance,
used with its permission.
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TOWN OF BARNSTABLE BUILDING PEk T APPLICATION
ci
Map Parcel o 4. Application # (3)0 . q_ v Gv 1 w
Health Division Date Issued 112_S A
Conservation Divisional Application Fee Y_
Planning Dept. Permit Fee / �5 0
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation / Hyannis
Project Street Address 121 iye'v-
Village L�
Owner 0_4�10 6 C Gd r a, Address ► ✓
Telephone - 71215 ,
Permit Request tram �� y7
C4 66A5 40 V4$-h1A(A
Square feet: 1 st floor: existing 6� proposed J✓ 2nd floor: existing proposed '� Total new
Zoning District 7 Flood Plain Groundwater Overlay
Project Valuation dSd� Construction Type
-4
Lot Size Grandfathered: Yes ❑ No If yes, attach.supporting::docu bentation.
� �w n
Dwelling Type: Single Family Two Family ❑ Multi-Family (# units)
�n
Age of Existing Structure Historic House: ❑Yes ❑ No On Old King-sHighway ❑Yet �No
Basement Type: ❑ Full Crawl ❑Walkout ❑ Other -
Basement Finished Area (sq.ft.) b Basement Unfinished Area (sq.fb -�
Number of Baths: Full: existin - new Half: existing twi _newl
Number of Bedrooms: &P L3 existing -new
Total Room Count (not in'�kjcling baths): existing new First Floor Room Count
Heat Type Ga yp and Fuel: Lg //s ❑ Oil ❑ Electric •❑/Other
Central Air: ❑Yes ZNo Fireplaces: Existing V New Existing wood/coal stove: ❑Yes Gee 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 /v I r G�OLG �� `%�'` Telephone Number `� i� U ��
Address 1�( '�a License # ®,5 6,,713
Home Improvement Contractor# G `
Email Worker's Compensation # 1,161 dolwm
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE f ,
r FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED
MAP/PARCEL NO.
7
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
FOUNDATION
4
FRAME
INSULATION lq
FIREPLACE
ELECTRICAL: ROUGH FINAL '
k
PLUMBING: ROUGH FINAL
f
ti
;► GAS: ROUGH FINAL
FINAL BUILDING o `1ht
DATE CLOSED OUT
f
ASSOCIATION PLAN NO.
A
_ - The ComnioTnfwealth of-Vassachusetts
Deparhent o,frudmbial Accidents
fQ,farce o,f Inves igadMIS
600 Washington Street -
c
ti •Boston,M4 O211
v
r►WIV.mass govIdia
Markers' Compensation Insurance Affidavit-.BidldersiCantracturslEIictricians(Plumbers.
Applicant Information Please hint
Legibly
Name�Sas®esstOrganizz��ianlndl� f a. ' Y 'hi
-
t�t ASS:
citylsItwizipc 11OF1B � glt� go,� 5 ,
Wan employer?Cheekthe appropriate box: ` Type of project(required):
1.Are
am a employes veith ❑I am a general contractor and I
employees(full audlor part-time)-* Have]sired the sub-contractors 6. ❑New construction
2.0 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
skip and have no employlees. These sub-contractors have 8 ❑Demolition
w°mo for nsse in g an i •en3ployees and,have woriers'
y capacity. -[No warloffs,comp.insurance coop.insurance 9. ❑Building addition
required-] 5. ❑ We.are a corporation and its lO.❑Electrical repairs or additions
3_❑ I am.a hameouner doing all work officers have their_ 11_❑Plumbing repairs or additions.
myself [No workers'ocmp- 11ght of exemption per.14IGL 12.❑Roofrepairs
irmura,nceregmi=ed]a c.152,§I(4�and vre have no
employees.[Na workers' 13.El other
camp-insurance required.]!
'Any WBcartthatchecksbox 91FnmsY also filloutthe secdonbElowshmmug fl=workers'compensatiouporicyinf m2fton-
H-ameownen who subunit This af6dnit indicating they are&wg all wat and then hire antside contractors amst submit a new affidavit indicating sach-
ZC3ntractor3 that Check this bME must attached an additional sheet showing the name of the sub-ca=zmm and state whether or not those entities have
employees.If the sub-connacturs have employers,they mootpmvide their workers'camp.policy number-
lam an emp&jwr that is protitiitc�yt! rkers�coirtpertsalion insrtra>tce,�or m}*enrpfoy�ee� Below is ate paticy and job site
inforatation r�
Insurance Company Name: .
1� S Policy#or Self-ins.lac. G E�pirat o'aBate: I Z 3
Job Site Address: L t`` 1C Ci lStafel -
Attach a copy of the workers'compensationpolicy 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 penald s of a
fine up to$UOG OD andf'or one-yeas imprisonmeutz as well as chit pen.alties.in the farm 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 fxwarded to the Office of
Investigations of the DIA.for insurance coverage mrification.
w I do herebycerttfy undq the 'ns aldpena 's peduxy.that the infbrnnatianPmided abut is bete td rorrect
- Si Mature- Date:
Phone iF- ✓�' 42
afjlldal use only. Do not twrfte in dds area,to be comptetad by c'artenrn ofieiat
City or Town: PermitUcense#
Issuing Authority(circle one): Y
1.Board of Health 2.Budding Department 3.Cityffown Clerk 4.Electrical hispt ctor S.Plumbing Inspector
G.Other
Contact Person: Phone#:
Information and Instructions ;
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation far their employees.
pmsrzantto this statute,au employee is defined as."—every person in the service of another under any contract of hfie,,
r
express or implied,oral or wrift em-
An ernpkye•is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged is a Joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of as individual,par acrsbip,association or other Iegal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occ¢pant of the -
dweU3ng house of another who employs persons to do mafiitm n ce,construction or repair work on such dwelling house
or on the grounds or bumldmg appurtenartt 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 buuldmgs in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance-coverage require(L"
Additionally,MGL chapter 152, §25((M slates"Neither the commonwealth nor iay of ifs political subdivisions shall
enter unto any contract for the performance ofpubho work until acceptable evidence of compliance with the fim ranch,
requirements of this chapter have been presented to the contracting mifhozityf _
Applicants
Please fill out the workers co msation affidavit completely,b ch the boxes that I to our situation if
' mp Y eclang apply Y �
necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificates)of
in crra„ce. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or piers,are not regtm ed to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is regnire B e advised that this affidayit may be submiLL-d to the Department of Indnshial
Accidents for confirmation Dfirsurancz coverage. Also be sure to sign and date the affidavit The affidavit should
o tense is being est not the D arfinent of
'o the,permit r h � eP
be rethnned to tme city or town that the application for p g�
Lnilust-iPI Accidents. Should
any you have questions regarding the Iaw or if you are required to obtain a workers
Y
compensation policy,pInse call tine Department at the number listed below. Self-insured companies should en�Ler their
s elf-iDmrcan ce license number on the appropriate Ire.
City or Town Officials
Please be sure that the affidavit is complete and primed legibly. The Department has provided a space of the bottom
of the affidavit for you to fill out in time event the Office of Investigations has to contact you regarding the applicant,
Please be sue to fill in the permit/Iicense number which wM be used as a reference number. In addition,an applicant
that must submit mubiple pemnit license applications in any given year,need only submit one affidavit mdicat mg current
policy inffbmation(if necessary)and under"Job Site Address"the applicant should write"all locations n (city or
town)_"A copy of t k 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 fuuinre permnits or licenses_ A new affidavit must be filled oixt each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or,commercial venture
(it_ a dog license or permit to bum leaves etc.)said person is NOT regtBred to complete this affidavit.
The Of of Investigations would lake to thank you i a 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 n>mberr.
The CGMMMWw dft of Masschus-r-Us
Depad meat of Indusft:ia1 Aot"Wen:L3
Q 7t�e of I vegUgatio-�
FQf�T�asbin�tQn �
Boston MA a1 I I I
T(,-L 4 617 7-4900(xt 4€l6 or 1-977=hASE�AM
Fax#617` 27 7749
Revised4-24-07 mar gQ�r dta
P
oFT"'E'Owti Town of Barnstable
°* Regulatory Services
Thomas F.Geile'r,Director -
''°rFo;►►�"�� Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601.`
www.town.barnstable.ma.us
Office: 508-862-403 8 Fax: 5087790-623 0
Property Owner Must x
Complete and Sign This Section
If Using A Builder
E
I Day) ob-( Vh: a
`s Owner of the subject pxoperty
hereby authorizeld� to act on m ;behalf,
in ail matters relative to work authorized by this building permit
/ 77
6u
(A of Job) f
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
Date
Q:FORMS:OWNERPERNMIONPOOLS 6/2012 .
i
Town of Barnstable
Regulatory Services
Thomas F.Geiler,Director
y MASS. g
Building Division
rFD MA'I A
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'dwellin6 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 strictures. 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) 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
0
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 Supervisbrs),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 forrrYcer•tification for use in your community.
Q:forms:homeexempt
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
Associated Employers Insurance Company`s
54 Third Avenue, Burlington, Massachusetts 01803-0970
(800) 876-2765 NCCI NO 40959
POLICY NO. WCC-500-5006114-2015A
PRIOR NO. WCC-500-5006114-2014A
ITEM
1. The Insured: Michael Deluga
DBA: Village Craft Building& Remodeling
Mailing address: 568 Santuit Road FEIN:**-***2146
Cotuit, MA 02635
Legal Entity Type: Sole Proprietor
Other workplaces not shown above:
2. The policy period is from 12/23/2015 to 12/23/2016 12:01 a.m. standard time at the insured's mailing address.
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the
states listed here: MA
B. Employers' Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A.
The limits of liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 100,000 each employee
C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B
D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE
4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans.
All information required below is subject to verification and change by audit.
Classifications Premium Basis Rates
Code Estimated Per$100 Estimated
No. Total Annual Of Annual
Remuneration Remuneration Premium
INTRA 355380
I INTER SEE CLASS CODE SCHEDU E
Minimum Premium $500 Total Estimated Annual Premium $2,638
IGOV GOV Deposit Premium $693
STATE CLASS
MA I 5645 State Assessments/Surcharges
$2,291.00 x 5.7500% $132
This policy, including all endorsements, is hereby countersigned by 10/20/2015
Authorized Signature Date
Service Office: Malcolm & Parsons Insurance Agency Inc
54 Third Avenue P 0 Box 527
Burlington MA 01803 Stoughton, MA 02072
WC 00 00 01 A (7-11)
Includes copyrighted material of the National Council on Compensation Insurance,
used with its permission.
j,
Massachuse f't
Massachusetts -Department Public a e y.
u*ilding......e.gul,
Board of B :Regulations and Standard.
q
ti
on Supervisor,ti Cons ruc
L. ice n s e:.CS-050.2.34
NUCHAEL-DELU
568 SANMT
COTUIT MA 02 5
Ex P i r at i o n .
co 07109/2016
mmis.sio*ner,
ofrke of Consu!-r—Aff i Fss Regulation
ME IMPROVEMENT CONTRACTOR
Type:
egisttation: ,105�48
xplratli`fi� 7/1-7/2.OA6, DBA
ff=_
N
6' RE �qDELIN
VILLA E CRAFT BJILD - G
i Michael Deluga
568 SANTUIT,RD.
COTUIT,MA02635 : 1
4
............
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Licenp.q.regi$q
Ptionyalid for individ on Y
ul use
before the expiration date. If found return t
t
0:1
Office 06nsumer Affairs and Business I Regulation10
Pprh Plaza-i Suite 51:70
130
stOn9 MA 02
116 mp
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7.
p
Not without si
valid lug
e,x
VILLA CRAFT
............
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V1L-Z,C-E CRAFT BUILDING&REMODELING.568 SANTU17. ROAD V'LLAGE CRAFT BUILDING&REMODELING DBF MICHAEL DEL Powered tsy Y.r.-ttWqt Payroli
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