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0117 ELIJAH CHILDS LANE
1 ,q LN . r o o e Town of Barnstable Building Post"This.r a`rd:So Thad ..is-Visible::From;the Street -'A roved Plans Must be Retained on Job°and this Card;Must�be Ke t•,,• �� .enrrrwsu C *7 dos ed,U�ntihFina[Ins a"coon Has.Been•Made � , ,6 P y x nc``is Re wired such:Butldm' shall Not be Occa ied-.until a.F nai_Ins ection;;has been made" , ; oct WherePe*rmit , : . a Certificate of Occupa y q g p Permit No. B-18-2778 Applicant Name: Dana Pickup Approvals Date Issued: 09/07/2018 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 03/07/2019 s Foundation: Location: 117 ELIJAH CHILDS LANE,CENTERVILLE Map/Lot: 171 269 Zoning District: RC Sheathing: Owner on Record: MILLER,JAMES E&CHARLENE J X Contractor"Name DANA J PICKUP Framing: 1 Y; TMR Contractor License CS 095228 Address: 117 ELIJAH CHILDS LN 2 CENTERVILLE, MA 02632 `` Est P roject Cost: $3,500.00 Chimney: Description: remove and replace 2 entry doors,same opening andSize . Permit Fee: $35.00 " Insulation: Project Review Req: A, X Fee Paid '' $35.00 Date 9/7/2018 Final: Y - - Plumbing/Gas �H ugi' Rough Plumbing: BuildingOfficial ,. �•,.,. Final Plumbing: . l This permit shall be deemed abandoned and invalid unless the work a t �d by this permit is commenced within siz months of#er issuance. Rough Gas: All work authorized by this permit shall conform to the approved application and the�approved construction documents for which this permit has been granted. �z �` All construction,alterations and changes of use of any building and strUctu-e'91 0l be in compliance with the local zoning,by�laws°and codes. Final Gas: .: This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public1inspeetion for the entire duration of the work until the completion of the same. Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are prowled onthis'permit. Service: Minimum of Five Call Inspections Required for All Construction Work: 1.Foundation or Footing �n "60 Rough: 2.Sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed _ Final: ' 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection - 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final:, All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT ONLavod GnATc. S�.rJ' 0 4 r Town of Barnstable *Permit# Expires 6 date "T Regulatory, months from issue Services Fee , _'j • snxxsrnBM « e Mass. Richard V.Scali;Director 1639. ArFO MA'S A Building Division Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-623 0 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY , t valid without Red X-Press Imprint Map/parcel Number Property Address 17 Fl-i TA It Cit l'&P-. Lie '. lit=to 1 Far yo IL& Residential Value of Work$ _3©0. 0 to Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address C H ftf rvr-,/ ,P- Al i LLER 117 E L,i T/I if CH J.0 S (,,N, C r F-/e-la��,�.,� Contractor's Name-®, 1A WC—B Telephone Number 6Y—.j 6 d—XV Home Improvement Contractor License#(if applicable) ) 1 b Email: Construction Supervisor's License#(if applicable) ©,/lvi ❑Workman's Compensation Insurance Check one: ® PEWIT � ,,. I am�a sole proprietor Y I am the Homeowner ❑ I have Worker's Compensation Insurance DEC 112014 Insurance Company Name TOWN OF BARNSTABLE Workman's Comp. Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) .p 8Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to�Yd�Tff' ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows #of doors: s ❑ 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 r requi_rJed. /1�0 SIGNATURE:, 'Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 061313 The Comma;rrswd&of MusaclntuseYts Deplrhamt of fidast id Accidents - Owe ofrM s6ga6ons 600 WasA&igton Stree-t J astany MA 0-1 W r wnw 7ti=g&Vdia ' vrkers' Campensation.Inswunce davit:Biiilders/mantr:actorslE ectriciausMumbers AppH ant Please Print Lep_ibly Names{Bryn oigsn atioaaufaidnao: I la City/StatcYzip_4--, i^& 06L5'3` _ phonC 47 6"' . Are you an.employer?Check fheappropriat>bax: T of. est •r_ atx�a:get�l contractor I �J ����- 1.El i am a employer with 4 I tor an 5- ❑Nffw oaasfr. oa employees(fall and/or par#-time)-* have hired th2 sub-contia dors 2_❑ I a n a sole proprietor or partner- hired on the attached sheet~ y- ❑Rp-rndelmg skip and have aG employees These sub contractors have g_ ❑Denwlifioa rcr n for in an c ci r_ employees an$have workers' Y aPa _ ❑Building addition i3lvQ±'1'�,2SS CorJ-p_rn�[;. coj'3-IY1Sllra11C� ` 5-❑ We area corporation and its If3_.❑El,ectiical repairs or additions 3.❑ am a,h i officers have exercised Their � m.�h�m�c�ner doing all work- .. ffi 11_.❑Plumbing repairs or additions myself [No woAmn,comps- right of eimmptionper MGL 17❑P'Sof repairs i--strrance squired I F c-152, §1(4} and we'hzveno, etisployees_[Na workem, 13_0 Other comp-insurance required.] ,Any spprx nt t.t chacks box r 1 mast also fill oiA the section helow.shawbig their worlaers�compessaa'iaa policy infunn-6al- t Homeac e s txbn sob=t$us affavvrt M& tm& sad Bien hae outride contractors—st skit a ner aytiavh mtliirp--ng smelt =Gunn crors that rhack this Goa most stiached Hu sdflitionsl sheet shoscing tlsA nam?of tie srRs x�md stain�cbenec�nuc tbnse end 7 Employe _ T_-&.srl?cont actors hive employees,thV must pimade%=r rror>; s'comp.policy I WMbrr_ I axr art empIo}�That is prmizhWg work-e-rs'costzperLsrtiun inswrrrac-e,f'or my e-mtpLoyem HeZaty is tfiep4Ary anal join sit-9 itifotmnfi�:� y Ins�nance Gomparry'ZFatne: ' Policy or Self-ins_Lim� F.xgirationBute. Job Site Addres: N 7 CPti 4S bq CifyrStafelzip�t/ 7 �t 7�i,�:. M }s Attzclt:a ropy of the-Porkers'compensation policy-declaration page(slwwing the policy-number and ej ration date). Failure to secure coverage as mjuiredundei Section 25 q o€MGL c. 152 can lead to the imposition ofcsimimal penalties of a fine up to$I,50Q_(}(}and/or one--year impri as well as civil penalties in the farm of a STOP WORK ORDER and a fine of up to$250_0.0 a day against the violator_ Be advised that a copy of this statemeut maybe forwarded to:the Office of Imr-estigation.s of f e DIA for inv ncc coverage verification- I dri hereby c rurd-�thspruns and panaW so, teary fhatthe inf ormatian pratided abrrve iss k-us and carrect SiEuature: Bate_ / Phon> 9' 0f,f iiiirL tz se only. Da rtat tt?rity!in this Area, v be campdeted by dlfv at town offic&L City or Town: _Pm-mtitUcense# Issuing Au-th ority(drde o rue): 1.Soarcl of IHezlfit 2.Building Department I Git.-fravm Clerk d_Electrical Fnsp ector S.Plumbing Trrspmtor 6.Other Contsrct Person. Phone#: 6 Information and Instructions Massachusetts General Laws chapter I52 requires all employers to provide workers'compensation for their employees. Pursuantto his statute,an employee is defined as"_..every person in the service of another under any contact of hire, express or implied., oral or writtem" 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 sues employment be deemed to be an employer." MGL chapter 152, §25C(6)also smt> s that"every state or Iocal licensing agency shaII withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonfi calth for=uy applicant who has not produced acceptable evidence of compliance with the insurance.coverage require.d." 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 tvidence of compliance wit'.the;n-sur-once requirements of this chapter have been presented to the contracting authority." Applicants — Please fi11 out the workers' compensation a�jdavit completely,by chcc'!dng the boxes hat apply to yrur situation and,i.f necessary,supply sub-contractor(s)narme(s),address(es)and phone n'mnbe,-(s)along with their cell'Ecaie(s) of insurance. Limited Liability Companies(i,LC) or Limited Liability PartnexsI ys(LLP)veithno ernrloyets other than the members or partners,are not rcgLred to carry workers' compensation insn ante. If an LL.0 or LLP does have employees, a policy is required, fie advised that this affidavit may be s?:bTzLLed to he Depa-tment of indusi-nal Accidents for confirmation of in-mane-average. Also be sure to sign and date the 2ffid2 t '11e affidavit sho Ad be returned to flip-city or town that he applica�on for the permit or 11CZDse is being requested, not the Department of Industrial Accidents. Shculd you have any quesions regarding the law or if you are regcued to obi-r a workers' compensation policy,please call the Department at the number listed below. Seii insured companies should enter heir self-insurance license number on Lot?rpropnate lme. City or Town. Officials Please be sure that the affidavit is complete and printed legibly. The Depattment has provided a space at the bottom of the affidavit for you to fill out he event the Office ofInvestigat ions has t.o contact you re-ardir.g he applicant Please be sure to fill in the permit/liceuse number which will be used as a referclace nUmber. In addition,an applicant that must submit multiple permitlLcense applications in any given year,need only submit one afEae vit indicating curer-t policy information (if necessary)and under"Job Site Address"the applicant should e"all locations in___(city or town)."A copy of the affidavit that has been officially stamped or marked by he city or town may be provided to the applicant as proof that a valid affidavit is oa file for futmc permi`s or licenses. Anew affidavit m,.>`rt be tilled out each year.Where a home owner or citiz-ea 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 N TOT requuired to complete this aifida it_ The Office of Investigations would!ikt to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a c;:I The Department's address,telephone and fax number_ ` �Commaaw--al$t of Massach-c—,setts D42LaltMeMt Gf 1ndustdal AQ6dr.Z.[S. Office 0 Vestiod1 if, 600 Washingt is St1�t fax r 617-`27- 7c9 Revised?-2'L07 X i 4�I�F=ERS9 COI�dPEIVSATION 5/ IUD 14lIPLOI(ER5 ,LJABJLITY IISiSURAIVCE POLIO( Atlantic Charter Insurance Company VDAC NCCI Co. No.:29211 Policy Number: WCV01168000 1. INSURED: Prior Policy Number: ' New Robert F. Tyndall h. Producer: 80 Brigantine Avenue O'Briens Centerville.Insurance Osterville, MA 02655 Federal ID Number:174560293 Agency, Inc. Risk ID Number. PO Box 610 Centerville, MA 02632 Business Type: Individual SIC:9999 NONCLASSIFIABLE ESTABLISHMENTS Other Named Insured:See WCE106. Other Work Places:. See WCE107 2. POLICY PERIOD: The Policy Period Is From: 7/11/2014 To :7/11/2015 12:01 A.M. Standard Time at The Insured Mailing Address 3. COVERAGES: A. Workers Compensation.lnsurance: Part One of the policy applies to the Workers Compensation Law of the states liste here: MA B. Employers Liability Insurance:_°Part Two of the policy applies to work in each state listed in item 3A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100,000 each employee,. C. Other States Insured: Part Three of the policy applies to the states, if any, listed here: COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06B D. This policy includes these endorsements and schedules: See WCE 105 4. COVERAGES: The premium for this policy will be determined by our Manual of Rules, Classifications, Rates & Rating Plans. All information required below is subject to verification and change by audit. Code ` Premium Basis Total Rate Per . Estimated Classifications No Estimated Annual $100 of Annual Remuneration Remuneration Premium See WC 00 00 01 Min imum Premium: Deposit Premium: $500 $500 Interim Adjustment: Annually Servicing Office: Estimated Premium (Minimum Premium) $500 25 New Chardon Street j Boston, MA 02114-4721 Issue Date 07/01/2014 Countersigned By:_ �_� Q�f .W� tied i Copvriqht 1987 National Council on Comoensatian Insurnnrp I � E rti Town. of Barnstable Regulatory Services * E * awaxsrABM 9 hUss. g .Richard V.Scali,Director Eo;q. Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, A I , as Owner of the subject property hereby authorize u ��.o �.(�IQ P) to act on my behalf, in all matters relative to work authorized by this building permit application for. 1 7 �%�elf G�t,L ®S g; aVI Url (Address of Job) I." "Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Signature of Applicant Print Name Print-Name t Dae Q:FORMS:O WNFRPFRMISSI0NP00LS Town of Barnstable Regulatory Services ��oF rOtyy Richard V.ScaIi,Director Building Division * BaxxsTna ; " Tom Perry,Building Commissioner arks. 1639. �$� 200 Main Street, Hyannis,MA 02601 TFO MP't a 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 4 CURRENT MAU-ING 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 permit (Section 109.1.1) k 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 35,00,0 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 &ReguIations 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 061313 - '� Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration 119766 Type: Office of Consumer Affairs and Business Regulation i Expration 8/28/201� DBA a i lO.Pairk Plaza-Suite 5170 Boston A 0211:5 WEBB CRAFT C�ESIGN DAVID. WEBB 25 MEADOW VIEW DR - I EAST FALMOUTH, MA G2536 Undersecretary Not valid without signature a P Massachusetts -De rtment of Public Safety Board of Building Regulations and Standards { Comi"Fliction Sup License: CS-046189 iD DAVHWEBB 32 F.R.Lillie Road c i R Woods Hole MA.712543 •• I . Commissioner ' Expiration 10/29/2016 JF 2 8s : 5l CAPE SAVE _DAI ' Weathenozation 508-398-0398 December 14,2011 Town of Barnstable Thomas Perry CBO Building Commissioner 200 Main St. Hyannis, MA 02601 RE: Building Permits Dear Mr. Perry, This affidavit is to certify that all work completed for permit application #201006346, Status A, Parcel 171269 at 117 Elijah Childs Lane, Centerville,Permit type: RADD, and issued on 12/03/2010 has been inspected by a certified Building Performance Institute (BPI) Inspector. R-18 Cellulose insulation was added to the attic.All work performed meets or exceeds Federal and State Requirements. Sincerely, William McCluskey Cape Save 7 Huntington Avenue Suite C, South Yarmouth, MA 02664 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application # �dGbo3�l�0 Health Division Date Issued Z 3 a Conservation Division Application Fee w Planning Dept. 'Permit Fee` 3 Date Definitive Plan Approved by Planning Board �, 2/31i0 Historic - OKH _ Preservation/Hyannis Project Street Address I 644-1 L�h It C"1 QS LA y- Village C&41�4-V1(A-E Owner MII14,C, JAM65 a44 C' L6&6 Address 117 (.1 F CMi LJ1S L*&6 Telephone T1(a Permit Request l M&)- (J (INSSULA O(J AAL) h CNWAL I (:EA-TbtJ Square feet: 1 st floor: existing proposed - 2nd floor: existing - proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation , O.Co Construction Type Lot Size Grandfathered: ❑Yes ❑'No If yes, attach supporting documentation. Dwelling Type: Single Family. 0' Two Family ❑ Multi-Family (# units) ._` Age of Existing Structure , j Historic House: ❑Yes LkNo On Old King`ws_Highway:'0 Yes)ffNo Basement Type: 6dFull 0 Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) I Basement Unfinished Area(sq.ft) Number of Baths: Full: existing Z new -- Half: existing new Number of Bedrooms: 'Z- existing ,new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: dGas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes 01No Fireplaces: Existing I New Existing wood/coal stove: ❑Yes 01qo Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: existing 0 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 1AJ1AjA1M A dI.Ai5i = Telephone Number 3ckE 033Sr Address JC. J�lA t KI nl92 i I J1= License # 102-777(o Q_ a A , Am* muoy Home Improvement Contractor# 1 'C 3 2-- Worker's Compensation # L) e 06 9 -9 f-b 9S f ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TOTWI b o t" SIGNATURE DATE k '# FOR OFFICIAL USE ONLY APPLICATION# -� Y• . t DATE ISSUED MAP/PARCEL N0._ k" ADDRESS VILLAGE OWNER' DATE OF INSPECTION: FOUNDATION FRAME Y V INSULATION-;. ` J,.' . r FIREPLACE ELECTRICAL: ROUGH FINAL ? PLUMBING: ROUGH FINAL GAS ' ' ROUGH i;A ' FINAL f FINAL BUILDING 'f'o zvJ_ °u. . S t - t DATE CLOSED OUT .. ASSOCIATION PLAN NO. �FTHE Tp� Town of Barnstable Regulatory Services BARNMBLF- ' Thomas F.Geiler,Director Mn.9s. 9�'�FoltAIb`�� 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. . F Property Owner Must Complete and Sign This Section if Using A Builder as Owner of the subject property hereby authorize iPl/hC ;;�j to act on my behalf, in all matters relative to work authorized bythis building permit application for: • (Address of Job) 1-0h Ica` Si ature of 0ffner Date Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the.reverse side. Q:FORMS:OWNERPERM ISSION _.. . _. _. .. s.y. :: .. I 1. . . . ::::::: ::.::-:::p::: �...: , " " " , , , -, - I ..- ....,. 11 .: :::: : ::::! :::::::- , "" �� ,,, �', �g"'g" , 5 I . .. I I.. I I--, ,,,t,,p4::&""�, � 1, I ," �5, a. I I . — .11, ...1.— Fl""'":: I I I,"" , -�N,I i, I . . I ,e � 11 . a_- .: ..: .: n¢ r r.;s ... ... :. .... �: d.:: .. .. :i� . ._ ._ �. .'.i :'. .-.:: 1.: .:::': .... .... -.: 1-:1 .. .. .. :::: ::: .,. ... .... . .: .. ... ..... _. :::: :::> .... _... ; !:. . . .. .... ..... ...... .. ..... _. .. .. .. :. :::: .. ._ .... :.. :: :.:: :.. .... -. ..... .._ .:::. ... .. :. ..:. ...... .... ... .... .:. ... .. ... tt u5t. 2: .: : °o hc�rra Ay c�hcerr� r . ill-- cC�c s ey �s r a cayee?e f� pe V. I. a i - 1.ut orize t� n gq. oa e ontr ds1. r�s b aI . .:: errn�ts for Q ar cca m I t :: !..:..:.::�I.:..:.::�1��1—.�.:.::1..'6:..:.�.�..:::."'-:.,.:.�:..�..:;1:,:.—:.�. ':,:.::--.::::.:::.::�J.:.::�:.:::-.:.-..,:-,.:A..,,:—:-�T:,.1���:*.1�.--:.:::::,.,:�::::.::l::--:,,:I::::.�::I.:::�—:::.�:;.:::.::,:::�::::'..:::::.:;:.::-:'.:::i.::::.:,:::i.:�:I-�,-:::..::;:::..p:,,:;�::..:. calcluey .I � .�'. ..:.-9 ,�: �::.:::::�:.::::�,,:::. :��:.::::::::�::::: ::: :...-.. . .. :: Cape Save—Unr . 15.5 3.5439 cell.:: :: . . ... 1. :: _. .. _ 1. 1. I. . . . . . . . . 1. _. _ _. .. 11 : 7C ur�t ri on A e , vut rr out: , __ 0 664 . . The Commonwealth of Massachusetts Department of Industrial Accidents Offlce of Investigations 600 Washington.Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance Affidavits Builders/Contractors/Electricians/Plumbers Aoulicant Information Please Print Legibly Name(Business/Orgaaizatioa%Individual). , CIA� �� Address: City/State/zip: Yvv1C Phone#: C '� �{ 0 Are you an employer?Check the appropriate box: ; t.311 am a employer with_ _ 4, 0.I am a general contractor and I Type of project(required): employees(full and/or part=tirne).e have hired the sub-contractors 6 ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. Remodeling ship and have no employees These sub-contractors_have g 0 Demolition working for me in any capacity. employees and have workers' [No workers'-comp. insurance comp. insurance) 9. ❑Building addition required] 5. (J We are a corporation and its 10. Electrical re pairs or additions 3.10 I am a homeowner doing all work officers have exerctsed their 11.0 Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.C1 Roof repairs. insurance required.]t c. 152, §1(4);and we have.no . 3a.❑ I am a homeowner.acting as a employees.[No workers' 13:�them general contractor(refer to#4) comp.,insurance required,) 'Any applicant that checks box#1 mast also fill out the section below showing their.workeas'compensatiod wicy information. t Homeowners who submit.this affidavit indicating they ate doing all work an&then hire outside conttactora.must submit a new.affidavit indipting such. :Contractors that check this box must attached an additional sheet showing the name of the sub-conwwtota and state whether or not those entities have employees. If the sub-conttacton have employees,they must provide their workers'comp.policy number. I an an employer that is providing workers compensation insurance for my employees. Below Is the po/Icy and job site Informadom Insurance Company Name: } Policy#or Self-ins. Lic.#: �, Expiration Date:- Job Site Address: Q�t t_t C A t ( City/S%tate/Zip:Cj� (j C� Z Attach"a copy of the workers'compensation policy declaration.page(showing the policynumber 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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator..:Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby eertifj►under the a and pe of perjury that the informmlon provided above Js true and correct i Offlckl 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. Bu ilding De partment g p artm ent 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: f^� ® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 11/1/2010 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 Shannon S errazza NAME: P Risk Strategies Company PHON o (781)986-4400 ac No:'(781)963-4420 15 Pacella Park Drive ADDRESS:ssperrazza@risk-strategies.com Suite 240 CUSTOMER ID ER 90018476 Randolph MA 02368 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA:Seneca Specialty Insurance Co INSURER BAeating Group Ins Services Michael McCluskey, DBA: Cape Save INSURERC:Chartis Insurance 7 C Huntington Ave INSURER D: INSURER E: South Yarmouth MA 02644 INSURERF: COVERAGES CERTIFICATE NUMBER:CL1011132675 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. INTR A S TYPE OF INSURANCE IN SR WVD POLICY NUMBER MML/D1YYYY MM DDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE ( RENTED PREMISESS Ea occurrence) $ 50,000 A CLAIMS-MADE a OCCUR RAG1002608 10/16/2010 10/16/2011 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 11000,000 X1 POLICY PROJECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON-OWNED AUTOS $ X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000 DEDUCTIBLE $ B RETENTION $ 023578601 10/16/2010 10/16/2011 $ c WORKERS COMPENSATION t4ichael McCluskey X I WC S LIMITS OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EXECUTIVE --- s excluded from coverage E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? Y❑ N/A (Mandatory in NH) 9930951 10/21/2010 10/21/2011 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,if more space is required) Issued as evidence of insurance. Contractors-Executive Supervisors or Executive Superintendents. CERTIFICATE HOLDER CANCELLATION (508)790-2425 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Housing Assistance Corp ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Ruth 460 West Main Street AUTHORIZED REPRESENTATIVE Hyannis, MA 02601-3698 Michael Christian/SMS ACORD 25(2009/09) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(200909) The ACORD name and logo are registered marks of ACORD = : __ _ __ ...__.. �� ... _ ... ... �: p : —.. 1. —I.— I - 4 ���, .��, I l.,: , �i��.:::�-.:::�,�::::::::::.::....::::��,:.:..:::::::::::::::::: : :::: :.: 11" , t � ,.j�",4::.::::::,::::�:::::::�:::w::::::::::,::;:: ::::; :q, . , ,,. Ca y .::: _. i I- x :. ,,; . :. .. . ' r rs � ' �` f a°' '. , as ,�:�� -i , -u.t a `! . � _ aaa , o . t. aY �Q CeCCY.`: . o [� ' cC uskey Js a . a l®yee'o�Cape Save � ' utha�rwz�d tc� �e�ra i to ontr ct51. bta id � per �. fir ou company. I , ::-M...I . -:1 ** Michael cCltuskey l-i;::,*:::::::::::,:::::::::::�:::!,:::::��.::.:-':',':I:.:.:::.,:: ,': -:-cd-I 1-,:.1:;1:1:-.::1:1 :.1.11111..111.-:1..1.1 1.I 1:1.I I.:.:,:,:..:.:..,.: ::.:*::.:;::*:::::::.:::..::1�.� �,I 1:i:::::�. ::..:I I:::::::-:p:� :::: ::�,:.,.� Cape have-Caner r 919-593 5939 cell _. :: :- . : ,: _. 7C W ntir gtoh.:Aven�a South Yarrnocat , t3266 .. .... _..._ . .... ,, t1:11 : .. .... ... __ .. _ . .... Town of Barnstable *Permit# 9! Expires 6 mont f om iss date Regulatory Services Fee r r BABNSPABM : Thomas F.Geiler,Director Ar°� Building Division �i 5�9�v3 ED MA om Perry,CBO, Building Commissioner MAY — 9 2008 200 Main Street,Hyannis,MA 02601 QQ onff www.town.barnstable.ma.us Office: oly PQ o RNSTABLEE Fax 508-790-6230 EXPRESS P�MIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number oc Property Address i r) a Residential, Value of Workc]�9 Cu3 • `` Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address 1'-1 1 l'� E-1 C e-�i 1 � o,3 Contractor's Name :.%L3 Tele hone Number C�,-- Home Improvement Contractor License#(if applicable) to ❑Workman's Compensation Insurance Check one: 12-I am a sole proprietor ❑ I am the Homeowner �l_have Worker's Compensation Insurance Insurance Company Name 1w 10-Uv C 2_s 4 . Workman's Comp.Policy# W a jA ' 4 t%' Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) r7 j i ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) &L_Re-side ❑ Replacement Windows/doors/sliders.U-Value (maximum,18) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e;Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License is required. SIGNATURE: QAWPFILESTOSM 'ding permit forms\EXPRESS.doc Revise020108 c � The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 . www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant InformationPag Please Prinnt�Le 'bl Name(Business/Organization/Individual): Address: City/State/Zip: C �,1 iy-M2V t 0' �- Are you an employer? Check the appropriate box: Type of project(required): 1.[I-I am a employer with t 4. ❑ I am a general contractor and I 6. ❑New construction . employees(full and/or. -time * have hired the stab-contractors 2.� I am a•sole proprietor or Fr- listed on the attached sheet 7. ❑Remodeling ship and have no employees These sub-contractors have g, E]Demolition working for me in any capacity. employees and have workers' 9 Building addition comp.insurance.$ [No workers' comp.insurance required] 5. We are a corporation and its 10.❑Electrical repairs or additions 3.El 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 §inarrrance required.]t c. 152, 1(4), and we have no 13.❑Other employees. [No workers comp.insurance required.] "Any applicant that checlts box 01 must also M 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-contiactors have employees,they must providt their workers'comp.poky number. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: e( Policy#or Self-ins.Lic.M V�! °f.�"�GZ y,4 (oSC,.) Expiration Date: (:T_ Ge Job Site Address: �� Ql.i t� -1 Cl t- City/State/Zip: �(���Z6?�t�IC \ 1 •U °�� Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secu rc 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 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. Si ature: Date: ,r Phone# 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 M f � 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 or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for.the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies•(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested.,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as 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 io 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 C6mmonwWih of Massachusd1s Dgwtment of lndusWal Accidents offlee of Investigations 600 Washington Street Boston,MA 02111 TO. #617-727-4900 ext 4-06 or 1-977-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.gov/dia 1 wr oF1HEr� Town of Barnstable Regulatory Services r �B" HASS"Blag," Thomas F.Geiler,Director 'OrFnts Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-623 0 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject \ J property hereby authorizes to. act on my behalf, in all matters relative to work authorized by this building permit application for: to ';v;3c.*k C kw (Address of Job) Signature of Owner Date Print Name } If Property Owner is applying for permit please complete the.Homeowners License Exemption Form on the reverse side. s. Town of Barnstable �pF YHE Tp�� y� o� Regulatory Services Thomas F.Geiler,Director BA"STABLE. q MASS Building Division PTfD eta Tom Perry,Building Commissioner . 200 Main Street, Hyannis, MA 02601 vvww.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 faun 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 pemut. (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 personas 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 fom✓certification for use in your community. �Z(THU), 16; 00 MALCOLM & PARSONS INSUKHNI.t �rr1A/ IIUI -I-- I ... ate IMMICONYYYI CERTIFICATE OF LIABILITY INSURANCE AMATTEROFINFORMATION07 CATE IS ISSUED AS A (781)344-3200 FAX (787J344-]425 ONLY NDTHIb ICONFERS NO RIGHTS UPON THE CERTIFICATE ,colm & Parsons Ins. Agcy. Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR �Freeman St- . ALTER THE COvERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 527 INSURERS AFFORDING COVERAGE ` NAIC A Stoughton, MA 02072 4-sUReD Jon Dunn IN9URCRA; Associated Employers Insurance DBA: John Dunn III NSURER B; P.O. Box 924 INSURERC: Centerville, MA 02632-0924 wauRnRD; INSURER L THE POLJCIEs OF INSURANCE LISTED BELOW HAVE BEEN ISSUED To THE INSURED NAMEO ABOVE FOR' POLICY PERIOD INDICATED,NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OFANY.CONTRACT OR OTHER DOCUMENT WITH RESPECT TO W HIGH THIS CERTIFICATE MAYBE ISSUED MAY PERTAIN,THE INSURANCE AFFORDED BY THE. POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TER MS,EXCLUSIONS AND CONDITIONS OF SUCH f 04ICIES,AOORECiAATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, UKSR PC CY CPM CT1rC POL Es AY pN TYPE O►.tNauRAwrq POLICY NUMDAR C.AC>1 occuRPGNt:G S OFNERALLMIUTY AMAO C T y COMM&CIAL GENHOL LIABILITY CLAIMd MADC O=UR MCD W(Any onv WWI i PERSONAL$ADV INJURY 5 OCNCRALAI30I:OA1t s pR000CTB•COMPIOP ADD S CCN4 A00ACOATt LIMIT APPLIES PM' POLICY .PRO- LAC AUTOMOOILC UADILITY COMBINeD OINOLe LIMIT S lFa occWonq ANY AUTO ALL OWNCO AUTOS BODILY INJURY s (Par Iwrtianl WHeDULCD AUTOS HIRED AUTOS BODILTINJURY ! (psroccwvnO NON4WNIP AUTOS PROPCRIY DAMAGE g (vrrcclCentl AUTO ONLY.CA ACCIDGNT S OARAOE LIADILITY 'U ACC S OTHRRTHAN ANY AUTO AU'IO ONLY! A00 $ -2EACH OCCURRENCE 9 ffxcj!=IJM15RELLA LIABILITY AOOREOATE _ OCCUR CLAIMS MADC 9 S O6DUGTiD4G s (leMINTION S w�a wORHCRacoMPCNSATl r u• a H• oNANd WCC5004658012007 09/29/2007 09/29/2008 .X _ EMPLOYERS'LIABILITYuA G.L.UACH ACCIDeNT S Sao 000 e A 0 PI SWMGMB6RPO GTlNUD6DF'iECUTIV6 6,L 3196A Q,5A.GMPLOYI. S SOO 000 p rc aacnw 9"481 C L.DISCASC•POLICY LIMIT s SOO 000 3 4PCyyww CIAL PROVISIONS WOW melt DESCRIPTION 0r OPMRRATIDNS I LOCATIONSI Vt:HIC4'Ga 1 rXct.uslONs AooEb BY ENDORSEMENT I al'CCIAL PROVISIONS Carpentry Contractor phn Dunn is covered by the Workers Compensation policy. , I CANCELLATION- CERTIFICATE HOLDER I SHOULD ANY OATHE ASOVIL 000CPIDI7D POIJCIgS D17 CANCELLED BCDORn7MC �1 !"IRATION DATC THCRCON,THd IsOUINO INOUROR WILL.CINDCAVORTO MAIL, DAYS WRITTEN NOTICE TO THD CORTIPICPS HOLDER NAMED TO THE 41!PT, Town Of Barnstabl t OUT FAILUR9 TO MA14 SUCH NOTICE SHALL IMPOSE NO OBL10ATION OR LIAOILITY Building DepSrtment OF ANY KIND UPON THE INOURtlR.ITS ACONTS OR R4PRzncNTATIVBS. Main Street Hyannis, MA 02601 AUTHORI pRGPROSgNTATNb PI-7 __j ; Irving Parsons cOACORD CORPORATION 1998 ACORD 26(200108) FAX: C508)790-6230 � a 4. �- a-c of-I sic t 7,,eg'Mtiov, nci Ss t:r c _ti }ik?E INiisJs�E.iVtENi G0[�JTRAGi�il I : t?yistratos 0i149 Expir tilt 6/J5/2008 . {�ti Typ Ind�v,idual ��, 1IT r' t +inn L u:rn a ,— =ri Mi �IL fai�ti TERRY N I ERt iL' E,MA 02632 a 'r Deputy Administrator ' l i ,. c Town of Barnstable *Permit# 9163y Expires 6 inont s om issue date rr g rY V( 1 �C='P PWIT Re ulato Services Fee APR 1.4 2006 Thomas F.Geiler,Director TOWN OF BARNSTABLE Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town bamstable.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 nt Do Property Address //! �I1� � �✓ 441• 9�6 Q Residential Value of Work Minimum fed of$25.00 for work under$6000.00 Owner's Name&Address V / ��/ ��/ Ie? CAA&t6 S. Contractor's Name : Tel hone Number Home Improvement Contractor License.#.(if applicable) Construction Supervisor's License#(if applicable) [iOrkman's Compensation Insurance Check one: . ❑ I am a sole proprietor ❑�,/I am the Homeowner F3 1 have Worker's Compensation Insurance Insurance Company Name /57' �' o Workman's Comp.Policy# � .7/l Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-s' e . +2 Replacement Windows. U-Value (maximum.44) *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 i 6 Ova •u+ 7i r0 'G Oo \ ' 9po .no •a Ai r♦O � `'\ ea to oc d ° oP ♦ ° y.,� �. mod' '`' '•,\ /= V y � � A d � 0 00 �C, i Department of Indushial Accidents Office of Investigations' 600 Washington Street '.' Boston,MA 02111 5••`' www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electridazis/Plumbers Applicant Information Please Print Lesdbly Name (Business/Orp=ation/individual): . Address: City/State/Zip: OM/Phone#: Amy5wlaiin employer? Check the'appropriate box:. Type of project(required):- 1. 1 am a•enyloyer with • 4. ❑ I am a general contractor and I ' 6. ❑New construction employees (fun'and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet $ 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. 7 Demolition working for me in any capacity. workers' comp.insurance. 9. El Building addition [No workers' comp.insurance 5. ❑ we are a corporation and its 10.0 Electrical repairs or.additions required.] officers have exercised their 3.❑ I am a homeowner doigg all work right of exemption per MGL 11-11 Plumbing iePairs 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 a new affidavith 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. am an emmy 7 information. Insurance.Company Name:_ Policy#or Self-ins.Lic.#: �l • / Expiration Date:' Job Site Address:/ �� � 60C_47WA1-5 City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to.secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$.1,500,.00 and/or one-year impnsomnent, as well as.civil penalties in:lie form of a STOPwORK ORDER and a line of up to$250.00 a day against the violator. Be advised that a copy of this statemenf maybe forwarded to the Office of Investigations of the DL4 for insurance coverage verification. I do hereby certify under the pains an pe aloes of perjury that the information provided above ' true and correct. sinafore: 7 Date:* l 4� Phone#: 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. 1 Pursuant to this statute, an employee is defined as ...every person in the service•of another under any contract of hire, e.Ypress or implied,oral or written. employer is defined as ?sm :;` ?ndivi¢ttal,:pardAers p,:associ ation,Forporation or other legal e�atity,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:tle use having not more than three apartments and who resides therein,or.the occupant of the owner of a dwelling ho dwelling house of another who employs persons to do maintenance, construction or repair woik�ou such dwelling house appurtenant thereto shall not because of such employment b e deemed to be an employer." or on the grounds or building I�IGL 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 comnnonwealth 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 iequirements 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. recessary,supply sub-contractor(s)name(s), address(es)and phone numbers)along with their cerdfieate(s)of insurance. Limited Liability Companies(I,LC)or Limited Liabm7ity 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' lease call the Department at the number listed below.. Self-insured companies should enter their compensationpohcy_,p._ _ . — —_ _ - self-insurance license number on the appropnate lme- — -- - City or Town Officials , ?lease 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 permit1cense 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 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 orliaenses..A new affidavit must be filled out.each yea .Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture year a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would bike 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.faxnumber: The Commonwealth of Massachusetts . Department of Industrial Accidents office Qf,�nvestigati®ns . f. 600-Washington$lreet� . Boston,MA 02111, `Tel.#617-727-4900 ext 406 or-l-877-MASSAFE Fax#617-727-7749 Revised 5-26705 www,mass.gov/dia Town of Barnstable Regulatory Segvice Thomas F.Geiler,Director �� ��� Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Fax: 508-790-6230 Office: 508-862.403 8 Property Owner Must Complete and Sign This Section If Using A Builder ,as Oumer of the subject property i to act on mp behalf hereby authorize in all matEers relative to work au, o=ecl by this building permit application(Address of Job) OJO e- a Owner Date s MILLi! Print Name Q:FORMS:09�1`�E� SIGN I_ Assessor's map and lot number ... .1..� %�,..:.0 ''. •• THE T� Sewage Permit number .... .."�.. . .........:........ .....:" rA= STEM RUST BMouse number E = BASB9TODLE, ............ 1 ............................................ . �p�IN 1COMPLIANCE '�Os�1639• ' ! $VM TITLE .5. CEO YPY a' TOWN' OF BAjmjfnE AN tj S BUILDING INSPECTOR APPLICATION FOR PERMIT TO J , TYPE OF CONSTRUCTION ......:�" : �f���-...:.... .......................................................................:............. ....................................' 19.o.L. y TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: %� ....... �r�,y `c.t�� G � Location ...... ........ G�.....�:.�.....................................�.::......:....................�................ . ................. ..................... ... ProposedUse .. U� �� . .............................................................................................................................. e Zoning District .....�....................................................................Fire District .................. Name of Owner ...✓!......r .....:��....................................Address .... ............................................ Nameof Builder .......... G ..Address........................................................ .................................................................................... Nameof Architect ..................................................................Address .................................................................................... Number of Rooms ...... ... .........................................................Foundation ... ,.t .............................................. Exterior .........'1 !i'•' eP...............................................Roofing ........041,9 S........................................................ Floors ......Q z`" " --..............................................................Interior ..........AC,�....... ..G��....................................... ............. Heating ......T.....................................................................Plumbing ........ ...... ........................................... Fireplace .......,.... .........................�............................................Approximate Cost ......... .1 ............. Definitive Plan Approved by Planning Board ________________________________19________. Area -..f��`;. ...... .......... 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. NanieI� / > 2 + SMALL, ALAN r PiJ i ' 231'S0. No ................. Permit for ...One...Story.......... ` ......Single...Fail?.7.�'..DWelling............... /Location ..?AQ)t... i3.a1Z...C•h lds Lane , ................................. Owner .. A.",an...Sz ......................... 1 Type�f Construction ...F.rame••••••.:•-•••:.'• ................... ........................................................... Plot *.................:....: Lot ................................ I fa.�' 2 8 • Permit Granted .......M..... ..........c..............:19 81 - -ILI A4 Date/of Inspection ....................................19 Date Co pleted ..... ....................8 �1�.19 o �. f WWI Ar I• ; ' P - REFUSED r .. i.f....... . .................... .... 19 tn ............... ............ ................ _ ....................................... 04 .............. .......................:Itc................ .... , •S_v i . Approved .......:.:...................................... 19 { ..... .... ................................. ......................... TOWN OF BARNSTABLE Permit No. ____233.30 h_ Building Inspector s,ein.at Cash OCCUPANCY PERMIT Bond 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 Flan Sinall - Address F Lot #44 'Elijah Childs Ian. Centerville Wiring Inspector , � !���=�-_" Inspection date Plumbing Inspecto f Inspection date Gas Inspector s f�..� � Inspection date Iv j011 V Engineering Department ��1 ,� ;� -. 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. 4 Building,Ifispector hk Assessor's. map and lot number ,.... q .f......: ( v s TN E p��y Sewage Permit number .... �..... .... .................� d� Z BARNSTABLE. i House number ..... 9 MUM .................. ................................................ p 2639. 00 MPY a� TOWN OF BARNSTABLE BUILDING- INSPECTOR �i�r� APPLICATION FOR PERMIT TO � ' TYPE OF CONSTRUCTION ��� p f ...............19.lI,l TO THE INSPECTOR OF BUILDINGS: I The undersigned hereby applies for a permit according to the following information: ;�— Location .'u.... .......�..A�oJr`! ..... ..N. .4 ...........�.<Ia.1,&._......:......c', 7U.a.:.....% «1„ ProposedUse ..�jf , ............................................................................................................................................ Zoning District ........................................................................Fire District : .:..... � Name of Owner � ....:*..Address Name of Builder ........................ �......`r ? r-' '� � ...Address ......... .............................................................. ...... Nameof Architect ...................................................................Address .................................................................................... Number of Rooms ........Foundation ... -� .............................................:..... .......................................................... Exierior .....:. ................................................Roofing ............ .................................................. Floors ......�.. ..............................................................Interior ........ lf......................................... Heating 'r. � ��' ............Plumbing -� .......................................................... ......, ... ................................................ Fireplace ..... .., .?.... ....................................... .Approximate Cost ....... ., ..................................... 4-7Definitive Plan Approved by Planning Board _____________________________ ,l9 Area ...�. '.da�...................... Diagram of Lot and Building with Dimensions Fee fr` 1- f.... SUBJECT TO APPROVAL OF BOARD OF HEALTH �\\ CJ AW i I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. ............................... FN LL, ALAN 171-269 315 0 Permit for ,One Story Single Family Dwelling 117 Location Lot...#44 " Elijah ........ Centerville ............................................................................... Owner ..Alan Small .............................................. Type of Construction .......Fr am 7*'**"*"*"**'*""* ................................................................................ Plot ............................ Lot ...// May 28 ,� 81 Permit Granted ..................�....................19 Date of Inspection ....................................19 Date Completed .......................................19 PERMIT REFUSED J ................................. ........................... 19 ............................................................................... ................................................................................ .......00.10-Ir. .......... .............................. Approved ................................................ 19 ............................................................................... ...............................................................................