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HomeMy WebLinkAbout0028 MARINER CIRCLE c"d i I'� 9 oFT r Town of Barnstable Permit# 7 I Regulatory SelC ee 6 months from issue date iARNSTABLE, i m• _ h - asess Richard V.Scali,Director j 3✓ . 7qj i639• N P , Building Division' MAY 9 'n' . Paul Roma,Building C� K%uer �O�l 200 Main Street,Hyannis, www.town.barnstable.ma us Office: 508-862-4038 &ax: 508-790-6230. EXPRESS PERMIT APPLICATION` - RESIDENTIAL ONLY O O Not Valid without Red X-Press Imprint Map/parcel Number 01u,Property Address Rovlzk+�- ZAQ_ CA.Q__C.L. C-C [Residential Value of Wo�rk `7900 Minimum fee of$35.00 for work under$6000.00 Owners Name&Address a.D,-)Vr- Contractor's Name Vzu-41. C;— Telephone Number S O J6 S®'q Lt 174 Home Improvement Contractor License#(if applicable) Email: GCcuA r AJ&A2.14,0 .V .a Construction Supervisor's License#(if applicable) Q q9 l�� ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor- ' Wam the Homeowner , have Worker's Compensation Insurance- Insurance Company Name 4CA�— Workman's Comp.Policy 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 4_4t_)0� �. ❑Re-roof(hurricane nailed)(not stripping. Going over. existing layers,of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows . #of doors: *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 llired. SIGNATURE: QAWPFILESTORMSUilding permit forms\EXPRESS.doc 01/25/17 nL 9 27ze Cowmamvea i rrf Afaysar*u efts Peparbneut af h sbi l Accidents ' 600 Washirrgtm S`reel , Boston,MA 02HI • tvrvw�nras���rlia - •. Warkere C ,ensatinnInsn-aasceAffidavit;13,ldlder�CimtracWrs/El�cfiricianslphnmbers APPUcant Tm rmatku Please Printf e: ly Name Addr LuJ ; CitylSitl Phans; __ 1{•� Are you an employer?Qt: eckthe appropriate bon Type of project(rajoi ed)_ L❑ I ant a employes veith. 4.❑I am a general confrsctar and I * have hired the sub�oanacbors 6_ Q New eomsliuctiotx • employees(fall.andfor part-time). , . . 2.❑ I am a sole propdetar arpartnw- - Mded on the attached sheet . 7. .❑Remodeling ship and have no emplayees - Thest smb-contractors base 8. Q Demolition worldng forme in any capaci4p_ et�zloyees audhaee xvoricess' ; 9..Q Building addition jNo tti-�ners'ooutp_ a COmP_tt'��'t'� • - regnired j 5. We are a corporation.and its 10:❑Elechical repairs or a dS inns 3111 ama homem mw doing ate word officers have exercised� ' IL0 Thnnbingrepaiss or ad(fitiams [No wo&ere - ugh of egempfion per M(M c.I52,§I(4handwehaveno lry Rflofrepais fxtcerras�rei2{p111E•C3,�1 ;l3_❑Other . employees.ff0twofers'. cozrp-insurance required.] $AnyRWiczvtd3scdmdabozIFlmastalsoi�onEthesethoabeiow�seiugBie¢wadcedcnmp apeTecgi�armsuc� ?Ek mwwn,erswho submit aus affidavg i—Hrad-i tLey ate&irk RU wok sad 1fim brie outside coscmrs—m1amit a near sffiazSr mdieat sudL ICanLacm�s$sat cfier7�this bmc mast aitarly�as additi�al sheet,sfioa tag t3eenazat of the snb coahscmrs and state whether arnat these erititieshaRe Mggayees.xthe snb-u�l=a empIoyw-%theymustpm-ide their srndmn'-mmp.palm m®ber_ lam an Er1igJar fiiat is prauidrrcg�a�arkers'canrpertsrrfrort ietsriranes fnr }a ePFu3�ees Setoav is�Ttop;r£icy�rum jata sites rnformalfam _ Insurance Ccmpaapi'6ame: "r Paficy 44,or Self--ins-Iic-t f j-R t Q SS) Z101q rmpiratm-nDade--5 GO Job Eta Address; -� ��1.e"(L l�nli 1 C41St W2e p: ,C M a'-l¢U Attach a copy of the worlce&compensatioapolicy declaration page(showing the'policy number and expiration d24 Failnre to secure coverage as required under Section.25A of MO-m 152 can lead to the imposition of criminal penalties of a fine up to$l,SQDOD avdf'or on-:earimpfisossmerd�as well asvivil penalties nr the farmi of a STOP WORK€]RDE zind a fine of up to$250-00 a day abpiast the violator. Be mhised that a copy of this sbdement sway he fc ri ded to the Office of IIIves igatiom ofthe DJA for insurance coverage vet an- I do IiMT y tits pains and n 's afperjW7 that the iisfara u6=pn -i&dabmw h true and correct Simature: Irate- Phone lk Offirial use wily, Do root ovate in thA Brea,fa be cvmp' £eteJ by city aartQara ojokra£ i.:rty or Town: PerrmtUcense f Bsuing Anfar4(dxde true): L Board of$eaIth BnTTring Dept 3.CUp Tows Clrxk 4.Uectriwl Iaspector a.Plumbing Easpecbr b.Other contact Person Phow#: ormatzon and lastructions warbos'campeeosaon fir them employers. • 7�(a e��I;,�se�fs Geoeaal Laws ffi�152 req=es all��m�& Ip>a to this sf�,an mpInymels dcfined as :.sverp personih ffie srdFice of anot3mr under any contract of drt. empress or iiapliee�oral or " a=c aHon;coxpora�on or other legal entity,or any two or more 1qn�Iay�is dei�cd as"an iad'ryidual,parfnership,, . of fhe:foregoing=gaged in a Joint ,amd mchzdmg fhe legal=F of a deceased employer,or f c or tmsf es of an mdrnidzzA partn.eshiP,assoeaafion or of =legal entity,employing employees- However the owner of a,dweDing house having not more tbm three apartnerds and who resides therein,or the occupant of the - dw eRing house of der who emzplays persous to do mamfenmce,caasftuzdOII or repair wow on such dwelling house or on the grounds or bm7dmg app�naUtIh=to sbaIlnotbecause of such enplayme�be deemed be an employer." MGL cbapter 152,§25C(6)also states tbat`°everystate-or local licensing agency ShallWnhold ffie issuance or renewal of a ficeaese or permit to operate a business or to construct buildings in the commonwealth for any applicant-Who has notproduced acceptable evidence of cdmpM-mc*with the hmurance_cov'exage required. Additio ,M CEE,cbaptcr 152,§25C(7)states'Teifherthe. nor wry ofitspoli ical subrFivisions shall enter m,`o any contract fur the perf�aaw ofpublic wodcu�I acceptable evidence of compliance with a msarznco- re�,�e�of finis cbaptrr have keen prex�to the eo�acfing anthorzCy." ' A.pPlicazxts Please fitI out the woxl�as'compensation affidav>t completely,by rheclssng$e bermes flat apply to you situation and,if nmc-sSaxy,sopPIY s)name(s), addresses)and ph==mbez(s) along withthea cetficat*)of insur iance. L ca t LiabilitY Companies(LLC)or Limited y Liabiilit Parineashzps(LLP)wifhno employeess other than the members or pis,are not nquiced to cant'wolkers'compensafian igs=mce If an LLC or LLP does have employees,apolicyisrMFdreL Be advised-f3iattbisaffidavitmaybesabmittsdtotheDepartmentofIndustrial Accidents mr confi<mafion of�'�cover age. Also be sure to sign and date the aisrdagit The affidavit should be retnmed to the cify or fawn that the application for the permit or license is being reque:ste:cL not$ie D epaii med of LnAmstag A cider, Sbanldyon bane any gnesti®s regarding the law or ifyou are req�io obtain a wogs' compensationpojiep,please call the Department atthen=bcrlistedbeLow: Self-insuredeompaniesshouldea the rir self-insurance license nmnber on the apprapzi line. City or TOWIL Officials t Please be sore that the affidavit is compleb a and priaird.legibly. The Department bas provided a space at tiie bottom of the affidavit for y esti�t;= the applicant you to trIl out in the event the Office of nv has to con zctyoa regM-c mg ape Pleas e be sure to fill in theP emiYHcense number which vM be used as a reference m=ber. Iu-addition,an applicant that mast submit multiple pemu�Iicense applZt�iions io:any even year,aced only submit erne affidavit indicaimg er.�'ent policy fi fo=xnatiou_(if ncressary)and under°Job Site Ad�ss"tie applicant shorld wri<e"aII loins n (may or town)"A copy of the-affidavitthathas been officially sfaz¢p ed or marked by the city or town may be provided to the ' applicant as yrooffthat a valid affidavit is on file for future pmmits or licenses- Anew affidavkMn st be IMCd out ear- year.Where a home owner or citi=is obtaining a license or pmmknot mlab, any business or comm='al v (ie-a dog license orpennit to burn leaves ems-)saidpemon is NOTregnimdto conopIete f ais affidavit The Office of Investig�w wouldlrke to tTiank you m advmw for your cocpeaatian and sboIIld you have any questions, please do not hesiiatr-to gC us a C- The Depffitlnenf's addr$ss,telephone and fax Cr.numb 'F1�f:anmon-maZtbEofl�hns ' Dqp�M±cif FsidI Accidents . • f�fce r�.f�g�tio� - _ Bagbou.,MA CdI11 TeL 4 617- -4 Q� E4€6 Or I-M MAAIq F' Fax 9 617` 27'749 R.evisxl 4.24-0 Tg r Town',of Barnsfable Regulatory Services MAW Richard V.Scab,Director s639. Building Division. Paul Roma,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 509-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder ,as Owner of the subject property hereby authorize aL, V C� to act on iri• y behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) - w **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 f inspections are performed and accepted. S' ture- Signature of Applicant Via/ DLO A . Print Name Print lame Date QTORMS:OWNERPERMISSIONPOOLS _ a Town of Barnstable Regulatory Services dF ibr._ Richard V.Scali,Director Building Division ser Paul Roma,Building Commissioner K039. IL AB& 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 - Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and 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 yermit. (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 this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q:\WPFELES\FORMS\building permit forms\EXPRESS.doc 06/20/16 r it _ 4 Massachusetts Department of Public.Safety Y Board of Building Regulations and Standards =` License:CSSL-099167 ,Construction Supervisor Specialty OLIVER M KELLY�' 4 8 RHINE ROAD YARMOUTH PORT . '{`,j.•vK CA-- Expiration: Commissioner 09128017 t, v ., C��?.P (per'?�?ZD�lZirflP��e��2 fy C�/��•� 1i1P��. .' , Office'of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston,-Massachusetts 02116 Home Improvement Contractor Registration t _ . A. Registration:' 12895777 - r Type: lridividual Expiration: 6/14/2017 Trit 266936 Oliver Kelly - f Oliver Kelly = ,� 8 Rhine Rd Yarmouthport, MA 02675 UpdateAddress and return card.Mark reason for change. sca I 0 2Cu-0sm Address Q Renewal E] Employment ❑Lost Card _ CV/71c 1111111ritalenS"o/✓l�i rrfit�eflJ C*Expiratlorr ice of ConsamerAffairs&Business License or Regulation registration valid for individul use only ' ME IMPROVEMENT CONTRACTOR before the expiration date If found return to: gistration: 1Z8957 Type: Office of Consumer Affairs and Business Regulation Individual 10 Park Plana-Suite 5170 Boston,MA 02116 Oliver Kelly Oliver Kelly 8 Rhine Rd. Yarrnouthpart,MA 02675 Undersecretary Not valid without signature F . - • f ye .tom f ACC>RL> CERTIFICATE OF LIABILITY INSURANCE 0DATE 5-15-2017 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 policy(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 CONTACT NAME: DOWLING&O'NEIL INS PHONE FAx 973 IYANNOUGH RD A/c No Ext: ac No): HYANNIS,MA 02601 E-MAIL INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:ACE AMERICAN INSURANCE CO INSURED INSURER B: KELLY ROOFING INC INSURER C: 8 RHINE RD YARMOUTHPORT,MA 02675 INSURER D: INSURER E: INSURER F: —COVERAGESCERTIFICATE NUMBER: 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 TYPE OF INSURANCE ADDL SUB POLICY NUMBER MhNDU EFF POLICY EXP LIMITS LTR INSR WVD ( /YYYY) MM/DD GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ PREMISES Ea occurrence —]CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL-AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY E JEC P LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accdent ANY AUTO BODILY INJURY(Per person) $ - ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED OPERTY AMAGE $ AUTOS er acadenl $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N X TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIV N/A E.L.EACH ACCIDENT - - OFFICER/MEMBER EXCLUDED? UB 05-10-2017 05-10-2018 $500,600(Mandatory - fyes,dsc in under 8HO85809 E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT -$500,000 DESCRIPTION OF OPERATIONS/LOCATIONS!VEHICLES(Attach ACORD 101,Additional Remarks Schedule,It more space Is required) TOWN OF BARNSTABLE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE 200 MAIN ST CANCELLED BEFORE THE EXPIRATION DATE THEREOF, HYANNIS,MA 02601 NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE JOHN J.LUPICA,President ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD i TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION � 2 p Map ®Z J Parcel a�(� Application #CDO S 6 e.�{ Health Division Date Issued Ll Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH. _ Preservation / Hyannis Project Street Address Village 4V ►�� / , / ,, / Owner Ti r�0 Address 3 i` ;t � � ^/� �"�✓-(- �y!�[ Telephone Po r 7 - '7 7 1 Z Z Z e> ✓Ll�l- d z I Sf Permit Request t72_,c.,(L i291e[A a4VL► ` _ . aJt w Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain r Groundwater Overlay Project Valuation (O ov-° Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family A--' Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes 0 No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other => Basement Finished Area (sq.ft.) Basement Unfinished Area (sLo Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor RFmcouqt,-, 9� rn Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other -� Central Air: ❑Yes ❑ 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 APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name �`' _ � � Telephone Number S?? -3 to Z -a v Address �� t�`)C 2 License # D YD e,tA1U44,r t 1J_ A d Z(O,3Z Home Improvement Contractor# 13 yY Ll 3 Email C ; Wl JY4-Uwa-e^^IDYI e.rC S e- e0w,-�Av1`tWorker's Compensation # V_ ALL CONSTRUCTION DEBRIS RESULTING FR M THIS PROJECT WILL BE TAKEN TO SIC G''V1tiJ SIGNATURE .1 i z FOR OFFICIAL USE ONLY r APPLICATION# DATE ISSUED MAP%PARCEL NO. r I ADDRESS VILLAGE. OWNER t DATE OF INSPECTION: { FOUNDATION ( rs6s d 13�I S FRAME INSULATION FIREPLACE r i ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL R• ` GAS: ROUGH FINAL FINAL BUILDING 'f DATE CLOSED OUT ` AS,SOCIATION PLAN NO. 6 s lne uonunonweatrn oimassacnuse= Depmtinent of Indusfrid Acc&eat v QJj7ce of Investigations 600 Washingfon Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit:Binders/Contractors/Electricians/Plronbers Applicant Information PIease Print Leeibly Name(BusinCW0rganization/Individua0: Address: 10 0 © x 1 City/State/Zip: ��iy �l/`✓� y� 1�� k n Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with m 4. I a a general contractor and I employees(fall and/or part-ti n )e * have hied the sob-contractors 6. ❑New contraction 2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. (Remodeling ship and have no employees These sub-contractors have 8. E]Demolition working for me in any capacity. employees and have workers' $ 9. 0 Building addition [No workers'comp.insurance comp.insurance. required.] 5. We are a corporation and its 10.0 Electrical repairs or additions officers have exercised their 3.❑ I am a homeowner doing all work= 11.❑Plumbing repairs or additions myself- [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance requirej]t c.152,§1(4),and we.have no employees.[No workers' 13.❑Other comp.insurance required.] *Any.applicant that checks box#1 most also fill out the section below showing theirworkers'compensation policy inkrmation. t Homeowners who submit this affidavit indicating they are doing all work and then hue outside contractors must submit a new affidavit indicating sucb. $Coatradnrs that check this box most atfachcd an additional sheet showing the name of the sub-contractors andstatr whether or not those eatities have employees. If the sub-contaidDrs have employees,they most provide their workers'camp.policy number. .1 am an employer that is pravuUV workers'compensation insurance for my employees. Below is the policy and job site information. Inm=w Company Name: ' �/0 �(/a-),-d f/12 0"v et_ e 0 Policy#or Self-ins.Lic.# �i 1 -f f Z- Expiration Date: Z h p Job Site Address: '� /►`�L 6 �,t Y`a-c- City/StatelLip: 0�� �- Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as regnued under Section 25A of MOL 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. Bo advised teat a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi underAe pains andpenaMes ofperlwy that the information provided above is true and correct Dat--: -U �I / Phone'A. 06, 9& ' Official use only..Do not write in this area,to be completed by city or town official City or Town: PermitlUcense# w 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 Msasssachusetts General Laws chapter 152 requires all employers to provide wadmrs'compensation for their employees. Pursuant to this statute,an enphyee 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 jomt enterprise,and including the Iegal representatives of.a deceased employer,or the receiver or trustee of as 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 contact for the performance of public work until acceptable evidence of compliance with the insu cc requirements of this chapter have been presented to the conir ding authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-confractor(s)name(s),addresses)and phone number(s)along with their certificates)of ins=Ge. 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 retnmed 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. T9ie 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 submif multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under`Job Site Address"tine 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 re 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 CLe. a dog license or permit to bum leaves etc.)said person is NOT required tut complete this affidavit The Office of Investigations would ac 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 CommoniF lth of Massachusetts Department of Industrial Miaidmts OfrLec of lavestiptions GOO Washingtan Street. Bostan,MA 02111 TcJ,#f 17-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07. Fax 4 f 17-727-7749. .m=.gGWdia Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 134443 Type: Ltd Liability Corpor Expiration: 10/29/2015 Tr# 245816 ENTERPRISES, LLC. — KEITH GILMORE POBOX 17 CENTERVILLE, MA 02632 Update Address and return card.Mark reason for change. L Address ❑ Renewal ❑ Employment Lost Card SCA 1 Co 20M-05/11 — C�lc�a�ir�a�nutaeull�r,�C%lla.u�tc�u�efLt License or registration valid for individul use only —Office of Consumer Affairs&Business Regulation � ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: "I t _ registration: 134443 Type: Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 ,`�%Expiration: 10/29/2015 Ltd Liability.Corpor Boston,MA 02116 ENTERPRISES,LLC. KEITH GILMORE 28 HIDDEN VALLEY RD. — MARSTONS MILLS,MA 02648 Undersecretary Not valid without signature f t 155.U_ .SILTS �r_•u,ir? i Of -;uouc Safev, . :a;^g -Req. iarr0^S ara Srandaras -se CS-098047 KEITH C GILMORE PO BOX 17 " CENTERVILLE MA 026�� Jx 0.-at;0r -_ 07/16/2015 Propoat Keith C. Gilmore Enterprises, LEC HIC#134443 _ P.O. Box 17, Centerville, MA 02632 MA CSL#98047 Phone: 508-420-9934 Fax: 508-420-993.5 Date: 10-14-14 Project#GIA01 Client Name: Tony&Josephine Giangrande Phone#617-771-2220 Billing Address: 893 Highland Dr.,Medford, MA 02155 Alt.# Fax# Project Address: 28 Mariner Circle, Cotuit, MA 02635 ]Email :jgiangrande@comcast.net Project Description: Install new 1/2" insulation board and Certainteed Monogram double 4"woodgrain vinyl siding. Install new white aluminum trim coverage to all fascia, soffit, frese,window,door and corner trim. Install white soffit vinyl panels to porch ceiling and soffit areas on the home. Install new white seamless aluminum gutters with downspouts. Install new Harvey white vinyl energy star rated replacement style windows to match existing openings without grids. Windows will have white hardware and half screens on double hungs. Octogon window and two slider doors to be replaced with new Harvey white vinyl units with white hardware and installed interior trims.Basement slider will have a Azek pvc base installed to frame. Design and construct a new 12'x 12'deck using pressure treated frame,new concrete footings,Azek Harvest collection decking,Azek white railing and upper post covers with post caps and base trims.No finish painting or staining of interior trims is included.No rot repair for trims is included in this estimate at this time. Rot repair will be quoted then billed as job progresses.A new garage door will be priced out as job progresses.Owner will supply new outdoor electrical fixtures.No shutters will be installed.Owner to select basic siding color. Project Task Items: * Design,permitting, labor, materials and waste total. $ 36,000.00 Total $ 36,000.00 Initials PAYMENT TERMS The amount or estimated amount of said contract is $36,000.00. Customer agrees to pay the Contractor according to the following terms: (wac,[�I $ 1,500.00 Due at scheduling $18,828.00 Due at material order $ 7,336.00 Due at window and door installation 1 t $ 7,336.00 Due at deck frame and start of siding 10 Utz Z M� $ 1,000.00 Due at completion p 7l Description of payment terms All work will cease under this contract if payments are not made pursuant to the terms described herein. Workmanship issues must be documented by the Customer,in writing,to the Contractor within fourteen(14)days that Homeowner knew or should have known. There will be no refund for special-order materials and/or any other non-stocked items after three days from approved proposal.Any other refunds shall be calculated and/or determined by Keith Gilmore Enterprises. The Contractor retains all legal remedies available if the Customer fails to pay including the recording of a mechanic's lien on the property pursuant to M.G.L.254,§5 to secure the payment of all labor, including construction management and general contractor services and materials,including those furnished by Keith Gilmore Enterprises. ,r- Customer guaranties the payment of all sums owed to the Contractor. Customer understands that any debt to Contractor over 30 days past due is subject to a 1'/z%finance charge per month(APR 18%). Customer agrees to pay all legal fees and costs incurred in the collection of any money owed to Contractor. Customer acknowledges that Keith Gilmore Enterprises has a reasonable expectation of payment from the Customer for any materials furnished by Keith Gilmore Enterprises as part of this project between the Customer and Contractor notwithstanding any payments to or disputes with the Contractor. This Notice of Contract is to be construed and interpreted accordingto the laws of the Commonwealth of Massachusetts. The undersigned acknowledge that they have read and understood all of the enclosed terms and that their signatures appear freely and voluntarily below: /0 z Z y Autho'zed Agent* D to 66nt tor bate /Oa,%y Page 2 of 2 Initiald�_ _,,,.-,Paychex, Inc. RF 2/1/2015 12 : 24 :46 AM PAGE 3/003 Fax Server .., CERTIFICATE OF LIABILITY INSURANCE �o;�5°i`'""`' 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•CONSTRO9 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 policy(ies)must be endorsed. It SUBROGATION IS WAIVED,subject to the terns and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not corder rights to the certificate holder in lieu of such endorsements. >RODUCER W.CT Paychex Insurance Agency Inc PAYggCHyyE�yX��,RINSURANCE AGENCY,INC. RHO %AW 11 NY RI E PHONE • 877-266-MO F • 585-389-7426 Certs@paychex.com INSURER(S)AFFORDING COVERAGE NAIL ff BRED INSURER A: NorGUARD Insurance Company 31470 KEITH C GILMORE ENTERPRISES LLC INSURER B• PO BOX 17 CENTERVILLE,MA 02632 INSURER C: INSURER D: INSURER I- INSURER R COVERAGES CERTIFICATE NUMBER: 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 MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECTTOALL THETERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMBS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. as TYPE OF INSURANCE POLICY NUMBER POLICY BFF POLICY EIIP LIMITS TR MW (fAWDDWM GENERAL LIABILITY EACH OCCURRENCE $ OM&.ERCIALGENERALLIABIUTY NET - $ =CLAW AMDE=]=R MED EXP(Any one p non) $ PERSONAL&ADV INJURY $ GENERALAGGIPEGATE $ LAGCAEGATEUMiTAPPUESPER PROCLM-CCW/CPAOG $ POLIDY O PROJEDT=I.0 $ AUTOMOBILELUIBILRY COMO�SINGLE UWr ( $ ANY AUTO �LY INJURY ALL OWNED O 6CNE OULED l'., '�) $ AUTOS AUTOS NON-OWNED BODILY INJURY HIRED AUTOS .AUTOS Per acddvt $ O PROPERI`(DAMAGE $ Per acddent $ UYOR ILIA IIAR O OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS•MAOE - A 7ATE $ DED RETENTIONS $ WORKER!COYPl NSAIKIN AND V WC ETATU',TK OTN- EYPLOYERS•LIAaIUTY KEWC631552 02/04/2015 02/04/2016 EL.EACH ACCIDENT $ 100,000.00 ANY PROPRIETOR/PA RTN ERIE AE CUTIVE � E.L.DISEASE•EA EMPUJYEE $ 100,000.00 OPPICERIMEMRER EXCLUDED? (YAnOAron I I� I III NN) N/A E.L.DISEASE-POLICYUMT $ SW,000.00 II YPa,mobs..a.,- )ESCRIFnM OF OPERAnCNS/LOCA7M/VENCLES(AtOdh ACORD I M,AdQtiarld Bartels 5aheoYle,it more spaoO IS reo}ire� CERTIFICATE HOLDER CANCELLATION Keith C Gilmore Enterprises LLC SHOULD ANY OFTME ABOVE DESCRIBED P000IISBECANCELLED BEFORE THEFXPIRA11ON P.O.Box 17 DAIETrERECF,N0110EW LBEDELNEtEDNA000RDMMWIIHIHEPOLICY Centerville,MA 02632 PWASlONS,BUT FAILUREIOMAILSUCHWnCESHALLWOSENOOBUGAnONOR UABIUTY oFANYMD IPONIIE COMPANY,rMAGENISOR REPREMffAlIVES. AUTHORIZED REPRESENTATIVE ACORD 25(2010/05) 01988.2010 ACORD CORPORATION. All rights reserved The ACORD name and logo are registered marks of ACORD a Y 52V2' A ire 5'-8 314' 5'-8 3/4' 4'-' Proposed (deck Rear �° � �°�- � �� �� n Scale 1/4" = 1' „0 Z :6 i,jy > t Keith C. Gikwre Ente ises 11C Cfi a isior►s= �, — —� -�Tony 8 Jose 'ne 6ia turd Pro•e • New 12' x 12' Deck M pa e� a-y�-M e w sea aa0�o�d t Me-a 28 Mariner Circle y —— C t if. MA 02635 Scalej U4' M Pressure Treated Deck Frame 16" O.C. Typ. 44 Pressure Treated Posts Anchored To 10" Concrete Sonotube Footings Using Simpson ABU44 Typ. 10" Concrete Sonotubes Placed 4' Below Grade Typ. Deck Ledger Frame Fastened To Home Using 4" Timberlock Bolts @ 16" O.C. Staggered Typ. 2x12 Pressure Treated Stair Frame On 6" Concrete Slab Typ. 5/46 Azek Decking With Azek White Railing. System Railing System To Be Installed _@ 36"' Minimum Height Off Deck Surface Typ. 44 Azek White Post Sleeves With Cap 8 Base Trims Typ. YAY 1 I i W-3 V4' 12�' Tr-8 3/4' V-8 3/4' F-8 3/4' Proposed Deck Frame Defai l Scale 1/4" = 1'0" Keith C. Gi1wre Er4erRdws LLC Cfie��.To 8 Josefte Via r Mist Revision vas=Tr .0 —rY n6� New 12 x 12' Deck t:2� e t 2 w 909 a28- M F,5��r 28 Mariner Circle —— BeCokuil;. MA 02635 ��: V4' Y0' �••ems•a•��e••�a.�w `fit a f _ , 35't Z_ w Ar x oK tv 49 Ae �a VN /L6) Do LL* 1E d l- 'n1 � p a' �{ LL. t c PLAN SHOWING io FOUNDATION LOCA TlM a 2 9kG O TUI T ASSACHUSE T T S �' � �_ `v'_ � �- m-zIt OWNED BY 7HE{j .'Cb01aT�.X=7'tc1r,� �0 > SCALE �� DATE: 10(2s jao i3 �v ? !}CC REG15TE a ttIUO.:SE R VE ..Y4R ) .HERE&f CERTIFY`7tfAT THIS FOUNDAPON IS :LOCATED `` � .,OF.M AN TWE OT..AS SHOWM AND CD'PIFORMS TO THE TOWN , - o RObERY_ QF RARNST'A$tE 40IWg6 R -6-ULA riONS REGARDInG > - RA'YMQND SETB_ :S, O.M. LINE LI LOT NES . " Qlo 2Y583 a: . el - ��Qt8'Tg��` 4 -.,.. lot' ' S. ATE .:j. 7777 or's map and lot number 4�.j/...'. .S.. �:. ........... Qe /" c'�';� 0S 7 f SEPTIC SYSTEM MUST Sewage Permit number ...... ...1................................ 1 NSTALLEp IN COM AHd3TA.DLE, i House number .......................:. .'.:.......................................... %MTN TITLE 5 ' MADE. �0 ENVIRONMENTAL CODE A 17 MA e TOWN OF BARNST�"ARVET'oNs BUILDING INSPECTOR APPLICATION FOR PERMIT TO .................. . ..... . ............... ................................................ TYPEOF CONSTRUCTION .... .: .............................. ................................................. 1 1920 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ..... �.......... ......4 .............................................................. Proposed Use ....... .............................................................................................................I.......................... 21 Zoning District f................................................Fire District .......CfIJ Nameof Owner .. G ... .. ........Address ............... ..............�. ........................ ... ................. Name of Builder /... .�....................IIU!)...............Address .................................................................................... 'lam.... ... Name of Architect ..................................................................Address ................................................................................... Number of Rooms ...................�..........................................Foundation ./...44&.... ` ................................. Exlerior A C.ee. -f...� ...Roofing .... � �� 17;P, . ... . . .. . Floors .... Interior .... � � � ................................................... l�......� ..... Heating / �.. ..................... �'.' ...........................Plumbing ..............��..... ............................................. // e r� Fireplace ............... .................................................................Approximate Cost ......... �.5� Q.......................................... Definitive Plan Approved by Planning Board ___ _ ._?___________19 __ . Area � !�..�•? Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ,— ............. ... ....... 2....... J CONSTRUCTION CO. .... Permit for One Story Single Familx Dwelling Location Lot #32 28 Mariner Circle ................................................. Cotuit ............................................................................... Owner Theo Construction Co. ............................................ Type of Construction Frame ................................................................................ Plot ............................ Lot ................................ Permit Granted ......QCtobe-r...3.0........19 80 Date of Inspection ....................................19 Date Completed ............ ....... Q N S PERMIT REFUSED T. Q 19 ..................................................� .M 71 .4................................................. ..... . to rn * ............................................... Approved ..........................I..................... 19 ............................................................................... Assessor's map and lot numbey,........................ ... ........... / c THE c Sewage Permit number ....` ................................................. d Z EAUSTAXLE, i HODS@ number ....................... ..'.......................................... 9�Os,M6 9 �00 •E�MPY a� TOWN OF BARNSTABLE BUILDING INSPECTOR t APPLICATION FOR PERMIT TO ..................... ............................ ......... TYPE OF CONSTRUCTION ...e���' ..... •- �?!>?( ......1�C .................................................. /'1 Z. & TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for,ra permit according to the following,information: Location ..... ....... ......! . t c r ........................ ................................... ProposedUse ....... f �. ............................................................................... .........................I......................... Zoning District ........................................................- Fire District .........fc/`G ............. Name of Owner /r �...<n?t�� U '/+r ?1... �.. K: ......Address ............. . ........ ...... .................. /�� �trf��� Name of Builder ...,..�,..,:............................................................Glue r'" Address .................. Nameof Architect ..................................................................Address .................................................................................... ' ! i Number of Rooms -� .....Foundation .. . �.................. ....................................... :............... <f.....::.......f.................................. Exterior Z./4?C..... \ GPI MI ..................... Roofing 1 /Cd � .(Est ,'.! .................................. Floor .............1..... .Interior l/ Heating ....,. ...,f!�...��J .. ...........................Plumbing ..............� ?.......!'Ci t•; ................................... Fireplace ..................................................................................Approximate Cost l 600 ;`..... ................................................. Definitive Plan Approved by Planning Board �t19,/ . Area Diagram of Lot and Building with Dimensions Fee ............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH t er 14 I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. / Name �7.C?/l .... G ; .............. 7 THEO CONSTRUCTION , A=2346 -38 . J No,.2.?6 2.9... Permit for ,Ong Story........... Single Family „Dwelling........... Location ...Lot 32 28 Mar;W.QK,,,.QirCle Cotuit ............................................................................... Owner Theo„Construction}..., Type of Construction .....Fr. MP......................... ................................................................................ Plot ............................ Lot' ................................ Permit Granted ..,October 3 0, 19. 80 Date of Inspection ....................................19 Date Completed ............................ 19 PERMIT REFUSED ................................................................ 19 . ....... ... . ....... I .................. ...................... . .............................. 6 Approved ................... ....... ..............1 19 ................................`. . .......................... ..................................... ........ ............................... � TOWN OF BARNSTABLE permit No. -------.___---------------- l Building Inspector s,un.n Cash �O 16JVA 9. OCCUPANCY PERMIT sons ----__________ ._ U "No building nor structure shall be erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to Address Wiring Inspector Inspection date Plumbing Inspector Inspection date Gas Inspector Inspection date Engineering Department Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. ............................................. .1 19......_ ........................................................._......................................... 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