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HomeMy WebLinkAbout0825 MAIN STREET (COTUIT) gas mn 'ln Si Application nup Wr .......................... — Fee............ ............................................................... 09 2911 Building Inspectors Initials....... .................... t63 6A STABLE �AA.�..... .�� Date Issued...............�. ........................ Map/Parcel........0... .� ,.., 77 .................1. �.J........ TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: 2 S 6fi - i+ NUMBER '�n '_ STREET VILLAGE/ Owner's Name: �,10�c, YY tr i r Via Y1 Phone Number (��� V "12-q 5O 2 Email Address: (�I rr►® lco�o��e��/her '°Gom Cell Phone Number 51gME- %J Project cost$ �J�UJc Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize t A ML4 to make applicatio r a buil ' permit in accordance with 780 CMR Owner Signature. Date: L l R TYPE OF WORK Ed/siding I Windows(no header change)#_--�-2 El Insulation/Weatherization 0 Doors (no header change)# Commercial Doors require an inspector's review D Roof(not applying more than I layer of shingles) Construction Debris will be going to CONTRACTOR'S INFORMATION Contractor's name tt)t, L l t 4, r Home Improvement Contractors Registration(if applicable)# j l Z 4 (attach copy) GS �o563�fn ' Construction Supervisor's License# �`�* - Ur p (attach copy) Email of Contractor Sb Phone number eon' 7 a 7 -4-0-2 ALL PROPERTIES THAT HAVE ftRUCTURES OVER 7S YEARS OLD OR IF THE SUBJECT PROPERTY/S/N A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. t 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 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 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. Signature Date APPLICANT'S SIGNATURE Signature Date All permit applications are subject to a building officials approval prior to issuance. 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/EIectricians/PIumbers Applicant Information Please Print Leeibly Name(Business/Organization/Individual): Address: 65- `5o w v►�+►11 City/State/Zip: m4lrb4ok,_� v I s oz e yk Phone#: Sod T6 ''7 y'P"71 Are you an employer?Check the appropriate box: Type of project(required): 1.[9 I am a employer with 1 4. I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 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 me in any capacity. employees and have workers' [No workers'comp.insurance comp.insurance. $ 9. ❑Building addition required] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.[1 I 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.[]Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' .131❑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 anew affidavit indicating such. tContraotors 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 subcontractors 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.Lie.#: �4)G G S� 4 e l OO 7 2017 Expiration Date: Job Site Address:. City/State/Zip: G p—/ a/ l 0 Z 5r-36 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 tine 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 p Was of perjury that the information provided above is true and correct Simatvle: Date: L G� Phone#: So 8' 7 3'7 ' 4i�'71 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#: ' 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 cr 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 comnionweilth 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(I.LC)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 ' A: +1.v 1 , r vro, Industrial Accidents. Should you Ydva any Tatt$uons —law u.7 .ara,rPrti±red to nhtilr ?WQrC_eLS' 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 permitilicense 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 firiure 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. - w 4•� The Commcmw alth of Massaahusu is DOgartment of Industdal Accidents fJfffce of Investigatlom 600 Washington St tct Boston,MA 02111 Tel.#617-7274900 ext 406 or 1-977-MASSAFE Fax# 617-727-7749 Revised 4-24-07 vt mass pv/dia ~ Act CERTIFICATE OF LIABILITY INSURANCE DATE(MMIODIYYYY) `� 1 1/8/2019 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 pollcy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER GONT UT NAME: Michael Edwards Lawrence Carlin Insurance Agency PHONE (508)540-7100 FAX (508)5e0-6426 ac No 230 Jones Road ADDRESS:Michael@ lawrencecarlin.com INSURERS AFFORDING COVERAGE NAIC It Falmouth MA 02540 INSURER A:Arbella Protection 41360 INSURED INSURER 13:Associated Employers Ins Co Schulze Building Company, LLC INSURERC: 65 Sawmill Road INSURERD: INSURER E: Marstons Mills MA 02648 INSURERF: COVERAGES CERTIFICATE NUMBER:CL1753001161 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. 1�TR TYPE OF INSURANCE L BR POLICY NUMBER MMIDD1f EFF PMIDD EXP LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE FO OCCUR IDAMA E (R N ED 100,000 PREM SES Ea occurrence $ 9520036828 3/5/2018 3/5/2019 MED EXP Anyone person $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENIAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY E a LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESSLJAB HCLAIMS-MADE AGGREGATE $ DED I I RETENTION $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIASILITY YINI STATUTE ER ANY PROPRIETOR/PARTNERIEXECUTNE E.L.EACH ACCIDENT $ 500,000 B OFFICERIMEMSER EXCLUDED? ❑N I A (MandaU"I.NH) MCC50050110072017 5/11/2018 5/11/2019 EL.DISEASE-EAEMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORO 101,Additional Remarks Schedule,may be attached If more apace is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Barnstable THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN Town Hall ACCORDANCE WITH THE POLICY PROVISIONS. 367 Main St Hyannis, MA 02601 AUTHORIZED REPRESENTATIVE David Lawrence/CAROL <2'o� 1 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) I^ ®� Commonwealth of Division of Professio assachusetts Board of Building Re nal Licensure Constry���gg lations and Standards CS 056340 �\ �P—qrvisor i X VIffLLIA r � ires: 1 012912020 s M L s6hu 65 SA LZE '. � MARSTfMIONS M Rg AD I . j MA�02648. COMM'.ssioner (ex . pp vnzaruuea/C/z a� aoaacLuaett a: �-\ Office of consumer Affairs&Business Regulation ix HOME IMPROVEMENT CONTRACTOR y TYPE:LLC Reaisrat!on Expiration s ffi2Q49�y 02/18/2019 y SCHULZE BUI i D W ILLIAM SCH LE 65 Sawmill Rd Marston s Mills,MA.p6#5 i:: - Undersecretary t FTHE t - Town of Barnstable *Permit#f 0 Expires 6 m the from r�sue date U �3' :Regulatory Services Fee BARNSTABCE `1639. Richard V.Scali,Director TOWN S IN Building Division Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bainstable.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 mv_k Property Address - -- Z /n, �ntA,�l &:)t Gyt Residential Value of Work$ Z- L Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name— 1�i Q lw �(/h y A,G_ Telephone Number c 60 �� � 7- y Jk?/ Home Improvement Contractor License#(if applicable) j/ �Z Email: S GG Construction Supervisor's License#(if applicable) G S y 6 3 y ❑Workman's Compensation Insurance Check one: SIP,am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy C_6 00 7 2 � Lo Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) . Re-side Replacement Windows/doors/sliders.U-Value /?9, (maximum.32)#of windows 4,u V0 d #of doors:_J_ ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. - *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: QAWPFILESTORMS\building permit orms\EXPRESS.doc Revised 040215 a . e Commonwealth onwea lth ofMassachwetts Depardnent of Indusiriai Accidents Orke afInvestigations 600 Washington Street Boston,MA #21.1I a 5 xvaul v.m gavldira Workers' Compensation Insurance Af av t: Builder-dContracturs�Electric ns/Phunbers Applicant Information Please Print Lgaly Name(Rusin t ,avizvafiwb iv dual):: 0 . /eft 1 Id k Inc.] Address: `�Gi(.J isl I l R0 rn, , city/state/zip: P vY1Cam. Mi )c Phone#: �6 -3 7 Are you an employer?Check the appropriate:box: Type of:project(required): 1,0 I am a employervaith t 4. ❑ I am$..general contractor and I la full andlor part-time)_* have hired the sa�b-comfactcus 6. 0 Rem Remodeling a� employees �' P� �- ? Rexmadelin 2.❑ I am a sole proprietor or partner listed on the attached sheet. ❑ g ship and have no employees These sob-contractors have g_ ❑Demoliticn w for me in an eamplovees and have workers' Wicking y cc 9. ❑Building addition. [No Eyoy�rg'comp_insurance comp.trisurame.1 required-] 5. ❑ We are a corporation and its 10-El Electrical repairs or additions 3.❑ I am a homeowner doing all work offacen have exercised their M❑Plumbing zi pairs or additions my-sAff [No workers'coamp- right of exemption per MGL 12..[_1 Roof repairs iusu=e required.]K c..152, §1(4X and we have no =pYe. lO es.INo tusarkeas' 13.❑other comp insurance riqugired.] ' •ttimy app catat i checks box#1 a1m t also fill an the section beiaw shawmg their wc*e&competgsatiou policy infaanaation. =F3<omeowmer3 who s0man this affidavit iat&catiarg they we doing all!wok and then lade outside Contractors mwst subnut anew affidavit indka= such- k�Datmctoas that check this box must attached as additional sheet showing the tie of the sub-camtrxiors aad:state whether or not those emAtees have employees. Ifthe hwe emytasgees,fin nn provide their workers'comp.policymmnber. I am an empty r thatisprai*Ung iworhers'compensate n bLvarance far my eurpinpee& B'e1ow is thepiaticy arrd;fob site informadon.. 1 Insurance Company Name: 1/' 4 rro Policy#or if=noes.Lie..#: �Gc''5��// 0� i Eaepira on late: 6/ A Job'Site Address: �ZS m,4 it) ef6 11, I City/State/Zip: Attach a copy of the workers'compensate policy declaration page(showing the policy number and expiration date). Fame to secum-coverage as required under Section 25A ofla+GL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500 00 andl'or one-year imprisonment,as well as civil penalties in the foimg of a STOP WORK ORDER.and a Ririe of up to$250.00 a,day against the violator. Be.advised that a copy of this statement maybe forvuarded to the Office of Investigations co€he DIA for in, umce coverage verification. Ida hereby fjP wooden'the onis and penahffes o f peduty that the its,f ormado n prof i&d a Bove is and carrect J. Date: Phone#: Official use only. Do not write in this area,Ai be completed by city ortawn affikial City or Town: PermitUcense# Issuing Authority(circle erne): 1.Board of Health 2.1lugding Department 3.CiWri own Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone##: OFTHE tp� + BARNSTABLE +} i 9� �.1659. Town of Barnstable 1��' 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 I, ►�� 1?�� , as Owner of the subject property hereby authorize ��� IY✓! �vh�/?.�� to act on my behalf, w in all matters relative to work authorized by this building permit application for: 14 r> � � (Address of Job) Si f Owner w Date t 11; VA no Print Name , If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. F QAWPFILES\FORMS\building permit forms\EXPRESS.doc Revised 040215 Town of Barnstable ' Regulatory Services �oFTHE TO Richard V.Scali,Director Building Division ` I* RARNSTABLE. * Tom Perry,Building Commissioner MASS. 9� 163q ,�� 200 Main Street Hyannis,MA 02601'ArFc Meg a www.town.barnstable.ma.us Office: 508-862-403 8 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-occuoied 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 undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. . HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 040215 ACo CERTIFICATE OF LIABILITY INSURANCE D/8/20DD'YYYY' 8/8/2014 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 pollcy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder In lieu of such-endorsement(s). PRODUCER ONT Michael Edwards Lawrence Carlin Insurance Agency PHONE (SOS)540-7100 IFAJXC. (503)540-8/26 230 Jones RoadE-MAIL .Michael@lawrencecarlin.com INSURERS AFFORDING COVERAGE NAIC I Falmouth MA 02540 INSURER A.Arbella Protection 41360 INSURED INSURERS Associated Employers Ins Co Schulze Buildina Co=anv,, T.T.0 PO BOX 288 1 SURERD: INSURER E Centerville MA 02632 INSURERF: COVERAGES CERTIFICATE NUMBER-CL148800640 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. INSR LTR TYPE OF INSURANCE* POLICY NUMBER MM/IDYL POLICY M DDY� LIMITS GENERAL LIABILITY _ _ EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RERTM occurrence)PREMISES(Ea 100,000 A CLAIMS-MADE a $ 5 OCCUR 8500050134 /5/2014 /5/2015 MED EXP(Any one person) 5 5,000 000 PERSONAL 8 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG E 2,000,000 X POLICY PRO-IFCT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT- nt ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident) $ AUTOS AUTOS ( ) NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Peraccident) S S UMBRELLA LIA8 OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE S --TOED RETENTION $ B WORKERS COMPENSATION WC STATU- 07H- AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? N I A (Mandatory In NH) WCC50050110072014 /11/2014 /11/2015 E.L.DISEASE•EA EMPLOYE $ 500,000 II yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION sbccapecod@comcast.net SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Canavan Construction Co. ACCORDANCE WITH THE POLICY PROVISIONS. 9 Emerald Tree Lane Plymouth, MA 02360 AUTHORIZED REPRESENTATIVE David Lawrence/MEDWA.R ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS117S,�nimclRl Tho arr1Arl Hama or.rl Innn ara ronialarorl marls of A(.r)Pr) IM Massachusetts -Department of:Public Safety. Board of Building.Regulations and Standards Construction Supen-isor License: CS-056340 wII.iJL M L sci 65 Sawmill Road Marstons Mills MA 4 Expiration i 10129/2016 Commissioner r . Unrestricted-Buildings of any use group Which contain less than 35,000 cubic feet(991m3)of r enclosed space. Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. r' For DPS Licensing information visit: www.Mass.Gov/DPS s TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 7 Parcel 6� Application# Health Division ®©s--Y . n 71 ,131Conservation Division �! 6G �/� ` Permit# Tax Collector Date Issued 00 Treasurer a d I Application Fee Planning Dept. TIN Date Definitive`elan ved by Planning Board LIMITED TO— J_#OF BEDROOMS Historic-ice Preservation/Hyannis Project Street Address O 2�I IWI/U 'd�/Z e—r Village 1l _ Owner �_ G n n o k) Address 5 MAIM Telephone Rtjoe C , Permit Request _ C,5 2� J loe E /? r fyv n 7` =zz `yiz* a 2 PAAn l CA--) e 4c,4 5/09 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 l6 0 Historic House: U Yes ❑No On Old King's Highway: ❑Yes ❑No r� Basement Type: ❑Full ❑Crawl O 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 O 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 / BUILDER INFORMATION Name �yIGLI�Qyy/ �G)ILILZe Telephone Number 7 'l1�— Address�S C�Ock "/2 j 1'/2LJd'7"" License# a yo C 9/0MIZ UAL L E Home Improvement Contractor# Worker's Compensation# A,( 6 70 -1 3— ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO ��h /,y-e &e SIGNATURE DATE q` /g O FOR OFFICIAL USE ONLY PERMIT NO. .DATE ISSUED- MAP/PARCEL NO. ADDRESS VILI:AGE OWNER r - DATE OF INSPECTION: FOUNDATION FRAME s INSULATION T' " FIREPLACE ELECTRICAL: ROUGH FINAL 1 PLUMBING: ROUGH FINAL X GAS: ROUGH tt3 FINAL S C? FINAL BUILDING 0 €q rn DATE CLOSED OUT ASSOCIATION PLAN NO. 0 i the L,umrnu"weaern ud lvluasucnusects Department of Industrial Accidents c Offce of Investigations a 600 Washington Street Boston, M4 02111 1y Y • www Haas&.g ov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information i Please Print'.L.ekiblY Name (Business/Organization/Individual): �L JLJ ill 1_ZL L DCQ• �-L� Address: 6�s obc k 4, City/State/Zip: 4��tI7-en V t L 6 Phone#: Sd g 7 71 - 6 Are you an employer? Check the appropriate box: Type of project(required): 1,0 I am a employer with Z 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 p=er- listed on the attached sheet $ Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself.[No workers' comp.- c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t 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 anew affidavit indicating such TContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. 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. #: 6 r7 0 Expiration Date: S // Job Site Address: O Z� /WA A.) -5-r• City/State/Zip: CC) ' 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$1,50Q.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 and penalties of perjury that the information provided above is true and correct, Signature: Date: Phone#: (610?) 7-7 I" C) 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 a.Electrical Inspector 5.Plu mbina Inspector 6. Other Contact Person: Rhone#: I Information and Instructions M . Massac usetts 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 ofpublic 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 lime. 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 mist 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 lime 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. t 617-727-4900 ext 406 or 1-o77-MASSAFE Revised 5-26-05 iaA + 617-727-7749 www.mass.gov/ciia f °Fr Town of Barnstable Regulatory Services �sasx S. Thomas F.Geiler,Director 16.19. Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-8624038 Fax: 508-790-6230 Permit no. Date AFFIDAVIT HOME 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 any 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: kr PC7 4..J1� Estimated Cost Address of Work: 25 �i /JL/ �/ . -a I t Owner's Name: hn r7o Date of Application: ��- Imo` d I hereby certify that: Registration is not required for the following reason(s): OWork excluded by law ❑Job Under$1,000 QBuilding 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 IMPROVEMENT 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: 0 � . Date Contractor Name Registration No. OR Date Owner's Name Q:forms:homeaffidav 1 aFISErct, Town of Barnstable ti Regulatory Services MASS. Thomas F.Geiler,Director 4'ppenj�� Building Division. Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner bust Complete and Sign This Section If Using ABuilder I, QUA � :E- IPAC 10,0-Or ,as Owner of the subject property c herebyauthorize Lyi �C��`y1 / �- to act on m behalf, � Y in all matters relative to work authorized by this building permit application.for: I�W) A.) J- r,4 i (Address of Job) 0 , ZY► l °� ' 06 of Owner Date DO OCA (-D PACh � h�� Print Name Q TORM&OWNERPERMISSION Residential Construction & Remodeling ® QUALITY& PRIDE P o. Box 288.Centerville, MA 02632 Schulze Telephone (508) 771-8604 BUILDING COMPANY, LLC Fax (508) 778-9141 Z- /A) O (ao� k1'b 41 �j CTo. mVJ-'P-� ) 3 o I )Yl`rP r a►� Lv I]V(� Z30 3/0 �J � i axn e-e wp�w zS N a-eo. aI (fAIA),)C-7r TO dG,c, r . k f 4 ��ze``�aini7ei� o� � � _ �• .. B®Alk OF BVILD0 GAEGULAklb,3S Licemsdi CONSTRUCTI:ORS:UPERVISO:R a Num6e CS 056340 Birat4954 E " 06 Tr:`no 3725.0 i L WILL!AM L SCHIILZt=� iJ;i E CENTERhUILLE, MA E}2632 I! Cernmissioner 1 _ 711xe �o7rvnza, Board of Building Regulations and Standards IZ I NONE IMPROVEMENT CONTRgCTOR Registrafron _ 12049 i �. T SCHULZE BUILD}N WfLLIAM SCHULZ ! PO BOX 288/65 CRQjgj1 CENTERVILLE,MA 02632 Administrator 4 N- j yld� - x,� U 3 1 q Town of Barnstable *Permit# y - t ? ". Expires 6months from issue date .}E Regulatory Services Fee , l Thomas F.Geiler,Director Building Division 4. Tom Perry,CBO, Building Commissioner �PRE. . 200 Main Street,Hyannis,MA 02601 . ERMIT www.town.barnstable.ma.us MAR I'o ,�n Office: 508-862-4038 TOwN OF Fax: 90-6230 OL- EXPRESS PERMIT APPLICATION RESIDENTILAL_ON LVqRNSTAeLE Not Valid without Red X Press Imprint r Map/parcel Number.0-3 5 O 63 Property Address gZ 5- / VIV "7/ - C�� T Residential Value of Work �� ��• Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address ,1�N46o Rb c-k n6QA �5 �✓Ik/A) 51 Cor44 Contractor's Name W 11-G>A07 56#414 Z,e Telephone Number (6708) 73 /4?7/ Home Improvement Contractor License#(if applicable) l/Z 0 7 9 Construction Supervisor's License#(if applicable) D 56.3 r. ♦J ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance Insurance Company Namerf�/U� Workman's Comp.Policy# 6-7 0 V rl Copy of Insurance Compliance Certificate must be on file.- Permit Request(check box) ElrRe-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) �Re-side VReplacement Windows. U-Value • 3 (maximum.44) '� w '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. Home Improvement Contractors License is required. SIGNATURE: Q:Forms:expmtrg Revise071405 f pUfMETO Town of Barnstable Regulatory Services • iAxrrsznai.E, MASS. $ Thomas F.Geiler,Director - skip. �m Alf 639�A Building Division. Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA b2601 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 F� I, (Pat— ,as Owner of the subject property hereby authorize (rL &_{-k LJ to act on my behalf, in all matters relative to work authorized by this building permit application for. (Address of job) SiEtfflof Owner Date V M k r\No Print Name Q TORM&OWNERPERMISSION 7k eammonweaaa aaaac/u�aek2 Board of Building Regulations and Standards HOME I OVEMENT CONTRACTOR Re l n`_ 120 c a 2007 Y. SCHULZE BUIL r WILLIA.M SCHU PO BOX 288/65 C CENTERVILLE,MA 02632 � Administrator