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Home My WebLink About1326 MAIN STREET (COTUIT) l3�� /��:�/ Ste' Town of Barnsta ble *PermitC # 0 Evpires 6 mr s rom A-sue d e Regulatory Servees Fee +" BARVS tBLE. y MASS. Thomas F. Geiler, Director Building Division Tom-Perry, CBO, Building Commissioner f 200 Main Street, Hyannis, MA 02601 www.town:bannstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - 'RESIDENTIAL ONLY Not Valid without Red X-Press Imprint, Map/parcel Nurnber a .3 Property—Address p� / �jiplP�c�l Residential Value of Work Minimum fee of$35.00 for work under S6.000.00 Owner's Narn e & Address Contractor's Narne Ve,-f go !l Telephone Number' r �✓Z' -- "—f. Home Improvement Contractor License#•(if applicable) Construction Supervisor's License#(if applicable) . r` ❑Workman's Compensation Insurance Check one: ❑ 1 l0i0 I am a sole proprietor - � 01 C T , ❑ I a e-Homeowner � TOWN �� A��ST��'� ` ave Worker's Compensation Insurance Insurance-Company Name ` c Workman Comp. Policy# 7` �"" . ,j ��-- 4 Copy of Insurance Compliance Certificate must accompany each permit, Permit Request (check box) Re-roof(hurricane nailed) (strippirig old shingles) All construction debris will be taken to (� �Tr° � �_ ❑ Re-roof(hurricane nailed) (not stripping. Going over existing layers of roo fl [f]!�Ze-side / of door's Replacement Windows/doors/sliders. U-Value (maximum .35)#of windows *Where required: Issuance of this permit does not exempt compliance wish 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 SIGNATURE: Q:IWPFILESIFORMSIbuilding permit for s1EXPRESS.doc Revised OM 10 Theo Commonwealth of Massachusetts ` Department of Industrial Accidents Office wf Investigations + d 600 Washington Street Boston, MA 021111 s� www.mass.gov/dia Workers' Compensation Insurance Affidavit:"Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual):. Address: P C? r City/State/Zip: ( ®�I r �7�"L h e Are y an employer? Check the appropriate bog: TM Type of project(required): 1. I am a y emp to er with A 4. I,am a general contractor and I 6. Q New construction employees(full and/or part-time).* have hired the sub-contractors 2:0 I'am a sole proprietor orpartner- listed on the attached sheet. 7. .0 Remodeling ship and have no employees These sub-contractors have g• Q Demolition ; working for me in an capacity. employees and have workers' g Y9. ❑Building addition [No workers'-comp.insurance comp.insurance.$ required.] - 5. Fj We.are a:coiporation and,its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.WPI b• g repairs or additions' myself. [No workers'comp_ right of exemption'per MGL 12. repairs insurance required.] t c. 152,§1(4),and We have no employees. [No workers' 13-El Other pomp. 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 andjob site information - Insurance Company-Name:.:. Policy#or Self--ins.Lic #: �� ! � xpiration Date: Job Site Address: �� ILsy� _ 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 tip 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 statemerit may be forwarded to the Office of Investigations of the DIA for"insurance coverage verification. ` :Ldo hereby"certt& er the pains d pe It' of perjury that the information provided above is true and correct Si afore: Dater D .40 ®` Phone#: , F only. Do not write in this area,to be completed by city or town'officiaL n: Permit/License_hority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector son: Phone#: S Informatrow-and-Instrucdons---- i 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 mcludmg the legarrepresentahves 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." • c , 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-contractor(s)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 iscomplete 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 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 Investigationts 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.gov/dia 01/10/2007 06:43 FAX �001 GCT-6*M1@ 12:46P FROM: 90W*70767 T0:16174 PA Town of Barnstable Regulatory Services Ae _ Thomas F.e'r ,er,Director sds Bunding Division Tom Perry,Budding COnuWWOUeF 200 Main WWI.Hyamis,TA 02601 W:+'trlAiwto.bar�astabiam8-u� . Office: 508-852-4038 Fax_ 508-790-6230 Property OwnerMust Complete and Sign Tl is Section If Usim .A,f3 ildear as Owner of the subject praperey hereby authorize to act on'my behalf, in all matccsa re &P-to work autboriaed by this bwl*PCrwk application f Or (Acidz�.ss of job) Sigssatiue a fawner sine If prol2e_lly, Q ►ner is applying for permit please complete the I-10meownexs License Exemption Form on the reverse side. OftteeTko�ff i•Altf i�&iViiiess gu License or registration valid for individul use only - HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: ;J Registration: ..-044322 Type: Office of Consumer Affairs and Business Regulation Expiration: ..9/23/2012 DBA 10 Park Plaza-Suite 5170 = Boston,MA 02116 GR VER BUILDING:fA-11 EMOQELING CAREY GROVER s 56 BOWDOIN RD 4��f C, MASHPEE, MA 02645, Undersecretary N valid without signature ... �_....._.......... . _._..,__.__. .... _ Nlussuchusetts - Department ()t•Puitlic-SafetN Board.of Building Re-ulutittns .uttl.Stun41urc1 . Construction Supervisor LiceJls� License: CS 77754 Restricted to:. 1 G k CAREY C GROVER PO BOX 1080 COTUIT, MA 02635 f' Expiration: 11/22/2011 ('unuuissiner Tr#: 7783 AC®RQ, CERTIFICATE OF LIABILITY INSURANCE °A08117/201� PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND Applied Risk Insurance Services, Inc. CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 10625 Old Mill Rd CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE Omaha, NE 6 8 1 5 4-0 6 4 6 - AFFORDED BY THE POLICIES BELOW. (8 7 7) 2 3 4-4 4 2 0 INSURERS AFFORDING COVERAGE NAIC # -- — -- INSURER A: Continental Indemnity Co. INSver, Carey dba Grover Building and Remodeling INSURERS: PO Box 1080 INSURER C: Cotuit, MA 02635-1080 INSURER0: CTL 1273 520498 INSURERE: 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 BEEN REDUCED BY PAID CLAIMS. INSR D6 - POLICY EFFECTIVE POLICY EXPIRATION ' LTR N TYPE OF INSURANCE POLICY NUMBER DATE MM/DDNY DATE MM/DDNY LIMITS GENERAL LIABILITY EACH OCCURRENCE S DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) S CLAIMS MADE❑OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY_ S GENERAL AGGREGATE IS _ GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S PRO- POLICY JECT LOC AUTOMOBILE LIABILITY ]COMBINED SINGLE LIMIT ANY AUTO (Ea accident) S ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) S HIRENON- AUTOS I BODILY INJURY NON- --- �— OWNED AUTOS � � (Per accident) j S PROPERTY DAMAGE (Per accident) I S GARAGE LIABILITY AUTO ONLY-EA ACCIDENT 5 _ IANY AUTO - - OTHER THAN EA ACC S AUTO ONLY: AGG S EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE— OCCUR OCCURRENCE_ OCCUR CLAIMS MADE �AGGREGATE S DEDUCTIBLE I $ RETENTION $ —� WORKERS COMPENSATION ANDOTH ---III EMPLOYERS'LIABILITY I TORY LIMITS; ER'___ _ ANY PROPRIETOR/PARTNER/EXECUTIVE 46-805700-01-03 0 8/31/10 I 0 8/3 1/11�E.L.EACH ACCIDENTS 500, 0 0 0 OFFICER/MEMBER E.XCLUnED? i EL DISEASE-EA EPAPLOYEE S 5 0 0, 0 0 0 . . if yes,describe under - SPECIAL PROVISIONS below I E.L.DISEASE-POLICY LIMIT S 5 0 0, 0 0 0 OTHER --- I ^ DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES!EXCLUSIONS ADDED BY ENDORSEMENT!SPECIAL PROVISIONS - CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Grover Building .and Remodeling EXPIRATION DATE THEREOF,THE ISSUING INSURER WILLENDEAVORTOMAIL_30 PO Box 1080 - DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON CO t w i t, MA . 0 2 6 3 5-1 0 8 0 THE INSURER.ITS AGENTS OR REPRESENTATIVES. _ - AUTHORIZED REPRESE Attn:� Project Manager ' 1783118 ACORD 25(2001/08) ©ACORD CORPORATION 1988 0. Town of Barnstable *Permit# C, Expires 6 montTO usrfe date Regulatory Services Fee u"9• Thomas F.Geiler Director Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 X-PRESS PERMIT.. ' Office: 5014a-403-8 Fax: 508.790-6230 S E P 2 1 004 EXPRESS_PERMIT APPLICATION: RESIDENTIAL ONLY Not Valid without Red X-Press Imprint TOWN OF BARRISTA�LE [apfparcel Number �✓3 O `�-?i roperiy Address I-T.7-fo Vim-V + S C a Oesidential Value of Work F o v_o u Minimum fee of-$25.00 for work under$6000.00 ►wner's Name&Address ?� + d`'� > ��i �,�-'�o tJ 6 L&C-+►`l :ontractor's Name �iT �'� ✓`''�`t-r l Telephone Number �o l- 4 7-to 5 3 6 come Improvement Contractor License#(if applicable) i t 0 �(�S ;onstruction Supervisor's License#(if applicable) '?fo�`3 ]Workman's Compensation Insurance . Check one: . ❑ I am a sole proprietor ❑ I am the Homeowner 'r [have Worker's Compensation Insurance nsurance Company Name iVorkman's Comp.Policy# 7-15 1 •2 i� r•Oft b o-! • �-+c ;opy of Insurance Compliance Certificate'must be on file. � C'fie�ommzoozu�eald� o�,�aaaaelzr,�eG 'ermit Request(check box) r Board of Building Regulations and Standards ❑ Re-roof(stripping old shingles) All construction debris will betaken to HOME I (,VEMENT CONTRACTOR ,.: El Re-roof(not stripping. Going over existing layers of roof) e a ,$ 2004 t ideal Ble-side r ['Replacement Windows. U-Value (maximum A4) *Where required: Issuance of this permit does not exempt compliance with other,town department 9+ C • ., -�� r�r� v��Q6rJ A:�rAia.ecS'6�i'e�;nr ***Note: Property Owner must sign Property Owner Letter of Permission. Home Improvement Contractors License is required. 13� �� L')ipatuxe ""004 °FtHE F, Town of Barnstable Regulatory Services BAM "UM , + Thomas F.Geiler,Director QED MA'I A`� Building Division Tom Perry, 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 T>a IJ-0 4.&6 A , as Owner of the subject property hereby authorize v%-CEtL"ems- to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) Y Signat&e of Owner Date J 1 r.I C7d rt,o�C-)►{ Print Name Q TORM&O WNERPERMIS SION