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HomeMy WebLinkAbout0191 MAIN STREET (COTUIT) ! I f & Iyt i I i Application number _J,..... Fee f.�.�J..��.............................. ...... ...... Ste : BUILDING DEP7 Building Inspectors Initials. L ....................... 16 FEB j ! Date Issued... ............................... 1�2 2020 TOW Map/Parcel..... �.1 /Ue, ..................... N OF BARNSTABLB TOWN OF BARNSTABLE - s EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOW S/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION - Address of Project: M.� v ;�T j e04L) I lv,A. NUMBER STREET VILLAGE Owner's Name: /qr J&tv G(IA�a*/ Phone Number 1�5 I q0 3 V SCANNED Email Address: Cell Phone Number 181010 Project cost$ . 500 w'+ Check one esidential Commercial .OWNER'S-AUTHORIZATION As owner of the above roe I hereb authorize !,- w T yG /off P P rty y__., �. �G B '� e d S X T to make application for a b ' ding permit in accordance with 780 CMR Owner Signature: Date: —27z--Izl TYPE OF WORK E3 Siding 0 Windows (no header change)# Insulation/Weathenzation 0 Doors(no header change)# Commercial Doors require an inspector's review Roof(not applying more than 1 layer of shingles) Construction Debris will be going to 3 V^19 ' U,9`&EA 71>110319 G .Yllfx art,vrw CONTRACTOR'S INFORMATION Contractor's name /¢DiG,f o i'' Home Improvement Contractors Registration(if applicable) (attach copy) Construction Supervisor's License# Q `3© E (attach copy) Email of Contractor 6GOyN;&�,0r/I?�/k.C,,Xhone number � �- 636 s ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT. YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER............................................................ t, i _*For Tents Only* i r' 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 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 non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with4he location(s)of each tent Fuel source being used LP tank 20 lbs. or>Yes No , if yes, a gas permit is required. 'Natural Gas Yes'- No , if yes, a gas`peermit is 1equired .a s If food is being served at your event please obtain a Health Department approval between the hours !CHIC { of 8:00am-9:30 am or 3.30 pm-4.30pm. Commercial events may require Fire Department approval, { *WOOD/COAL/PELLET STOVES * i Manufacturer# Model/I.D. .Fuel Type Testing Lab Offsets from combustibles: front M 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 hraccord'ance with 7804CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town f Barnstable. Signature Date _-APPLICANT'S SIGNATURE (.� fi ' Signature � � ., Date 'All permit app adons are subject to a building official's approval prior to issuance. r 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 Ugibl_y Name(Business/Organization/Individual): ��GDC.i/+�� CO,Vf rAV C r(r'WV Address: 1)71,1740AI I.A'NG , City/State/Zip:)V ,C S T#,O 0idf 0.2 i4t?Phone#: 631 6ioS Are you an employer?Check the appropriate box: Type of project(required): 1. B I am'a employer with '` 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, []'Demolition working for in an capacity. employees and have workers' g Y P tY• 9. ❑Building addition [No workers' comp.insurance comp. insurance.: required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12 pkoof 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. #Contractors 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 and job site. information. Insurance Company Name:. Policy#or Self-ins.Lic.#: Expiration Date: 0.0i A 3 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 under the pains nd penalties ofperjury that the information provided above is true and correct Signature: Date: Phone#--- - -- - _ _ - - - -.. _ ----- - -- - --..---- -- - - - -- --- -- - -- - Of use only. Do not write in this area,to be completed by city or town offciaL 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#: y. Information and Instructions f 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 commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-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 dreference 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 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 42111 Tel.#617-727-4900 ext 446 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia DATE(MM/DDIYYYY) A�v CERTIFICATE OF LIABILITY INSURANCE 05117/19 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 CERTIFICATEMOLDER. IMPORTANT: If the certificate.holder is an ADDITIONAL INSURED,.the policy(ies)must.have ADDITIONAL INSURED provisions or be endorsed: if SUBROGATION IS.WAIVED,subject to the'terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER N JIM HINDMAN ' Schlegel&Schlegel Ins Broker PH o t- 608-771.8381 A c No: 508-771.0663 34 Main Street ADDRESS:schlegelinsuranceggiviall.com West Yarmouth,MA 02673 INSURERS)AFFORDING COVERAGE NAIC# j INSURER : NGM INSURANCE COMPANY _ 14788 INSURED INSURERB: AIM MUTUAL Adilson Segolird INSURERC DBA SEGOLINI CONSTRUCTION INSURER D 117 Minton Lane W Barnstable,MA 02668-1818 INSURER E INSURER F. COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS ISTO CERTIFY THAT THE POLICIES.OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE:POLICY PERIOD INDICATED. NOTWITHSTANDING REOUiREMENT,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. LTR TYPE OF INSURANCE _ D POLICY NUMBER MM/D MMIODIYYYY LIMITS X COMMERCIAL GENERAL LIABILITY? EACH OCCURRENCE S 1,000,000 CLAIMS-MADE �OCCUR PREMIS DAMAGEES(Ea occurrence) S 500,000 MED EXP(Any one arson $ 10,000 A MPT8486U 05107119 05/07/20 PERSONAL&ADV INJURY S 1,000,000 GEN'LAGGREGATEUMITAPPLIESPEP, GENERALAGGREGATE $ 2,000,000 POLICY❑PRO- ❑LOC a PRODUCTS-COMPIOPAGG "S 2,000,000 JECT $ OTHER: COMBINED S NGLE LIMIT $ AUTOMOBILE LIABILITY (Ea. ANYAUTO BODILY INJURY'(Peiperson). S OWNED .. SCHEDULED BODILY INJURY(Per acciiant) S AUTOS ONLY AUTOS <` PROPERTY PPEERR e DAMAGE HIRED HIRED NON-0WNED AUTOS ONLY AUTOS ONLY r - S i UMBRELLA LIAB OCCUR EACH OCCURRENCE S EXCESS LIAB CLgljyjg MADE AGGREGATE $ DEO RETENTIONS § WORKERS COMPENSATION STA UTE ER AND.EMPLOYERS'LUIBILITY 100,000 ANY PROPRIETOR/PARTNER/EXECUTNEY/N E,L.EACHACCIDEN7 $ 40,000 B OFFICERIMEMBER EXCLUDED? ® N I A AWCr400-7026096-2015 05123/19 O5/23120 E L DISEASE EA EMPLOYE S 510,000 r (Mandatory In.NH) Ii yyes describe under E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OFOPERATIONS below DESCRIPTION.OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it none space is required) ADILSON SEGOLINI HAS ELECTED TO BE COVERED UNDER HIS CURRENT WORKERS COMPENSATION POLICY • a w r CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLEDBEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. CUSTOMER COPY, AUTHOR ZED REPRES A E 2015 ACORD CORPORATION. All rights reserves ACORD 25(2016/03) L• The ACORD name and logo are registered marks of ACORD, - aikeotca�merlr>�ies3HReg�aNa, - r HWE flt�CONTRACTOR Registration valid for use only before the eon dam. 1f*m*rwurrttcc EmIration -OfOce of Consumer Aifaira end Suss ess:Ran —�� _06114=0 1000 Waahtngton Street-Sulte 710 ADUON SEdd ti- ' Boston,AAA 02118 D!8/A SEGOUNI a�0 0-SON ADILSON SEGO I e 117 MINTON LANES = � WEST BARNSTABLE.iI�A ass_ = _ Nat valid W00ut 919nature Ur�elsry Commonwealth of Massachusetts Division of Professional Ucensure �` T Board of Building Regulations and Standards , Constructii �p� r Specialty I �pires:1011412021 �� T CSSL-099907 _ x AIMON 11T.MINTONt1AnMIE .r WEST � Commissioner