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HomeMy WebLinkAbout0070 ELLIOTT ROAD r a. o J a r L D71 TOW GF AR 3 TABLE RISE Division of Thielsch Engineering,Inc. 7012 WAR I AN.1�: 06 1341 Elmwood Avenue ENGINEERING Cranston,Rhode Island 02910 a,=j F Thursday, February 23, 2012 Town of Barnstable Thomas Perry, CBO 200 Main Street Hyannis, MA 02601 RE: 170 Elliot Road; Centerville, MA Barnstable Building Permit#: B20120317 Dear Mr. Perry, This affidavit is to certify that all work completed at 70 Elliot Road; Centerville, MA,has been inspected by a certified Building Performance Institute (BPI) inspector. The following insulation was added: ➢ Install a 4" layer of R-14 Class 1 Cellulose to 320 square feet of floored attic space. ➢ Install a 4" layer of R-14 Class 1 Cellulose to 320 square feet of floored attic space. ➢ Install one Therm-a-dome (or equal) R-14 insulating stair cover with a,perimeter of plywood. ➢ Install R-19 unfaced fiberglass.blockers to the sills. 75 square feet. All work performed meets or exceeds Federal and State Requirements. Sincerely, Erik J. Nerstheimer RISE Engineering Residential Installations Department RISE Engineering; A Division of Thielsch Engineering 401-784-3700 •800-422-5365 -Fax 401-784-3710 � 125591 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map- . '�ya Parcel OSY Application #awl a 00.�3 Health Division Date Issued 2 Conservation Division - :Application Fee Planning Dept. Permit Fee, Date Definitive Plan Approved by Planning Board t Historic - OKH — Preservation/ Hyannis Project Street Address 70 ELLIOT ROAD Village CENTERVILLE Owner PHYLLIS A DUNN Address 73 BROAD REACH #M41C Telephone 781-331-0806 N. WEYMOUTHi MA 02191 Permit Request PERFORM AIR SEALING MEASURES; INSTALL CELLULOSE INSULATION TO FLOORED AND OPEN ATTIC AREAS; INSTALL MOVABLE STAIRWAY COVER (THERMADOME) ; IN�TALL VENTILATION CHUTES. (PROPAVENTS) TO OPEN ATTIC AREAS; INSTALL INSULATIN TO BASEMENT SILL.. SEE ATTACHED COPY OF CONTRACT. Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation $2,522.68 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ,❑ Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King�'_Highway ❑Y s ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) t Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ 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 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 RISE Engineering; A Division of ThielsclTelephone Number 401-784-3700 EXT AM 6133 Engineering Address 1341 Elmwood Ave, Cranston RI 02910 License# 100459 EXP. 3/12 Home Improvement Contractor# 120979 EXP. 3/12 Worker's Compensation # 3730961-01 EXP.1/1/13 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO RI Resource Recoyery, John on, RI SIGNATURE DATE c)L IL3 Erik Nerstheimer for RISE Engineering s C FOR OFFICIAL USE ONLY APPLICATION# } __DATE ISSUED .'_MAP_/PARCEL NO. ADDRESS VILLAGE OWNER - DATE OF INSPECTION: .. - :. _ FOUNDATION'F FRAME INSULATION - FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL "j GAS Y `" ROUGH K: =i *, FINAL { -L-3 FINAL BUILDINGS.•t iTNVA t 'a rs , DATE CLOSED OUT 'J, r - z ASSOCIATION PLAN NO. i The Commonwealth of Massachusetts Department.of Industrial Accidents Office of Investigations J -- 600 Wash engtonStr Street ' _ ' - Boston MA 02111 www.mass.gov/dia Workers' Compensation Insurance Aff davit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): RISE. ENGINEERING; A DIVISION OF THIELSCH ENGINEERING Address: 1341 ELMWOOD AVENUE City/State/Zip: CRANSTON, RI 02910 " Phone#: 401-784-3700 OR 800-422-5365 Are you an employer? Check the appropriate box: Type of project(required): 1. X❑ I am a employer with 4• ❑.I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction ,. 2.❑ I am a sole proprietor or partner listed on the attached sheet. •, 7. ❑ Remodeling ship and have no employees.. These sub-contractors have 8. ❑ Demolition , working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp. insurance comp. insurance.t .❑ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs + insurance required.]t c. 152, §1(4), and we have no employees. [No workers' 13.0 Other INSULATION comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. ' t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such:- $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. w I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site. information. N Insurance Company Name: THE PRESTON AGENCY, INC Policy#or Self-ins. Lic.#: 3730961-01 t Expiration Date: Ol/01/13 Job Site Address: 70 Elliot Road City/State/Zip: Centerville, MA 02632 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that copy of this statement may be forwarded to the Office of-. Investigations of the DIA for insurance coverage verification: - I do hereby certi un r th ains d penalties of perjury that the information provided abo a is tr and correct. Sianature: Date: �- _. ERIK NERSTHEIMER FOR RISE ENGINEERING Phone#: 401 '784-3700 EXT. 6133 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): .x 1. Board of Health:2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing:Inspector ,x 6. Other Contact Person: Phone#: f "1 THIEL-1 OP ID: 27 CERTIFICATE OF LIABILITY INSURANCE °ATE'MM'°°"""' 01/13/12 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 - 401-886-8000 CONTACT _ . The Preston Agency,Inc. NAME: 1350 Division Rd Suite 303 401-885-1700 PHONE o Est:. nAic No):. PO BOX 810 E-MAIL East Greenwich,RI 02818-0810 ADDRESS: Judith A.Wright CPCU AAI ARM INSURER(S)AFFORDING COVERAGE NAIC 0 INSURER A:Zurich-American INSURED Thielsch Engineering,Inc. wsuRERB;American Guarantee&Liability ° Thielsch Group Inc. HI Tech Realty Inc. INSURER c:Twin City Fire-Hartford Attn:Trent Theroux INSURER D:North American Capacity 195 Frances Avenue Cranston,RI 02910 INSURER E: . INSURER F: . 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 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 INSURANCEADDLSUBR POLICY EFF POLICY EXP LTR POLICY NUMBER MMIDD/YYYYI (MM/DDrNYYi LIMITS GENERAL LIABILITY - - - - EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY X 3730962-01 DAMAGE TO RENTF 01/01/12 01/01/13 PREMISES Ea occurrence $ 300,00 CLAIMS-MADE I A I OCCUR ` - MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000-,00 F GENERAL AGGREGATE $ 2,000,00 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 POLICY X' PRO- LOC Emp Ben. $ 1,000,00 AUTOMOBILE LIABILITY - COMBINED SINGLE LIMIT Ea accident 2,000,00 A X ANY AUTO 31730963-01. 01/01/12 01/01/13 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) •$ AUTOS AUTOS ) NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident) $ X UMBRELLA LIAR X OCCUR - o- EACH OCCURRENCE $ "10,000,000 B EXCESSLIAB CLAIMS-MADE AUC-4857188-01 01/01/12 01/01/13 AGGREGATE . $ 10,000,000 DED RETENTION$ $ WORKERS COMPENSATION , - _ WC STATU- OTH- AND EMPLOYERS'LIABILITY YIN - _ X 1 RY LIMIT ER A ANY PROPRIETOR/PARTNER/EXECUTIVE 3730961-01 - 01/01/12 01/01/13,, E.L.EACH ACCIDENT - $ 1,000,00 OFFICERIMEMBER EXCLUDE D9 ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE4 $ 1,000,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT. $ 1,000,00 C Property Section 01_] 12UUNHE6930 01/01/12 01/01/13 Property see Belo D Professional Liab DVL000026802 01/01/12 01/01/13 Prof Liab 2,000,00 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES.(Attach ACORD 101,Additional Remarks Schedule,If more space Is required) - When required by a written contract. CERTIFICATE HOLDER CANCELLATION TWNHARW SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Barnstable THE EXPIRATION DATE THEREOF, NOTICE,WILL BE DELIVERED IN Building Division': ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street AUTHORIZED REPRESENTATIVE _ Hyannis,MA 02601 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05). The ACORD name and logo are registered marks of ACORD t_II,CI1bVU vt;tdilb Page 1 Of 1 The Official Website of the Executive Office of Public Safety'and-Security(EOPS) MamGov Home- Public Safety Department.Of Public.Safety Licensee-Complaints License Type Construction Supervisor License# 100459. . . . . .- Restriction N/S,IC Name Erik Nerstheimer City,State,Zip North Scituate;Rl,02857 Expiration Date 3/28/2012 Status Current • No coirkpiairitstoutx!is*th± Licet:;ee. Back-;To Search i �1 f�.�.1t111rA.40f1� .. Klli •rl,t-13- ' i(41r 11�l1►i- niru�i cns t lj6 ul:(tir' Lic r ;i rl !'tLi.SL � to: S ,RestricteW � 9 - ERllc.NERST 228 GLEAN- HEI MER NORTH ER CHAPEL ROAp. . SCITUATE R,0285NOV 7 �..rr.r EzPr'atic�n: 3/28/2012 ;. . Tr. 10045g• f hftp,.//db.,Stato.ma.us/dps/licdetails-asp?txtSearchLN=CSL1 00459 4/20L201.1. . _ 4 g1te O ice o onsumer Kio/atn_d usiness e u anon g 10 Park Plaza - Suite 51.70 "- Boston, '44ssachusetts 02116 Home Improve contractor Registration _ Registration: 120979 Type: Supplement Card pP i ! Expiration: 3/25/2012 THIELSCH ENGINEERING r ERIK .NERSTHEIMER i 1341 ELMWOOD AVE.: CRANSTON RI. 02910 �r ` �$s s � Update Address and return card.Mark reason for change.. Address E Renewal ❑ Employment Lost Card DPS-CA1 it 50M-04/04-G101216 �/ie 1�oz�irrco�ziueal�i ��� - - 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: Office of Consumer Affairs and Business Regulation Registration;' 79 _ Type: 10 Park Plaza-Suite 5170 " Expira2012 Supplement Card Boston,MA 02116 L THIELSCH ENG(�}� ry l ERIK NERSTHEI _.� 1341 ELMWOOD AVE CRANSTON, RI'029`F(.~,=`- I Undersecretary _Not valid without signature f t i Control No:. 34244 `THE COMMONWEALTH OF MASSACHUSETTS Al DEPARTMENT OF LABOR e DIVISION OE..00CUPATIONAL SAFETY~ ' 19 STANIFORD STREET, BOsTON,N ASSACHUSETTS 02114 LEAD-SAFE RENOVATION CONTRACTOR LICENSING WAIVER RISE Engineering A Division of Thielsch Engineering, Inc. 1341 Elmwood Avenue Cranston; RI 02910 WAIVER: LW000672 EXPIRES: April 15,2015 IN ACCORDANCE WITH M.G.L. C. 111, § 197(B)(b)AND 454 CMR 22.03(3)(b); THIS LEAD-SAFE RENOVATION CONTRACTOR LICENSING WAIVER IS ISSUED BY THE DIV. OF OCCUPATIONAL SAFETY TO THE CONTRACTOR ABOVE FOR THE PURPOSE OF PERFORMING LEAD-SAFE RENOVATION WORK. THIS LEAD-SAFE RENOVATION CONTRACTOR LICENSING WAIVER MUST BE MAINTAINED BY THE CONTRACTOR IN ACCORDANCE'WITH M.G.L. C. 111, § 197B(b)AND 454 CMR 22.04 WHEN°PERFORMING LEAD-SAFE RENOVATION WORK. ' HEATHER E. ROWE,ACTING COMMISSIONER Printed on Recycled Pape"r - - RISE ENGINEERING Federal ID#05-0405629 RI Contractor Registration No 8186 A division of Thielsch Engineering MA Contractor Registration No 120979 CT Contractor Registration No 620120 1341 Elmwood Avenue,Cranston,RI 02910 " - �`Feees (401)784-3700 FAX(401)784-3710 CONTRAPT n 1� U .. Page 1 ?, - 'PROGRAM THIS CONTRACT IS ENTERED-0 BETWEEN RISE3:� ` CLC-RCS ENGINEERING AND THE CUSTOMER<F,OR W0. AS - E NCU!N EE Al N G DESCRIBED BELOW _. CUSTOMER . 1'�, ��[�) .�- w PHONE ,. DATE Client# • Joseph D Dunn r_�(Y C-e cl S Ci f I N� Li_1S 'f U N1 (781)331-0806 11/10/2011 125591 SERVICE STREET - BILLING STREET LE G 70 Elliot Road r 73 Broad Reach#m4lc D SERVICE CITY,STATE,LP BILLING CITY,STATE,ZIP Centerville,MA 02632 N.Weymouth,MA 02191 J�� .1 8 2012 JOB DESCRIPTION Provide labor and materials to seal areas of your home against wasteful,excess air leakage. This work will be performed in concert with the use of special tools and diagnostic tests to assure that your home will be left with a healthful level of air exchange and indoor air quality. Materials to be used to seal your home can include caulks,foams,weatherstripping and other products. Primary areas for sealing include air leakage to attics,basements,attached garages and other unheated areas(windows are not generally addressed.) $560,00 Provide labor and materials to install a 4"layer of R-14 Class 1 Cellulose added to 320 square feet of floored attic space. $364.80 Provide labor and materials to install a 9"layer of R-31 Class I Cellulose added to 836 square feet of open attic space. $1,070.08 Provide labor and materials to install an easily moved,insulating cover for the attic access folding stair. A small flat surface of plywood will be created around the opening within the attic. This will allow the cover's integral weather-stripping to restrict air leakage. $220.00 Provide labor and materials to install ventilation chutes in(54)rafter bays to maintain air flow. $172.80 Provide labor and materials to install 75 square feet of R-19 unfaced fiberglass insulation to the perimeter of the basement ceiling at the house sill. $135.00 - RISE Engineering will apply all applicable,eligible incentives to this contract. You will be billed only the Net amount. Currently,for eligible measures,the Cape Light Compact offers a 100%incentive. $560.00 k RISE ENGMER NG 'Federal ID#06-0405629 RI Contractor Registration No 8186 A division of Thielseh Engineering AA Contractor Registration No 120979 CT Contractor Registration No 620120 t 1341 Elmwood Avenue,Cranston,RI 02910 (401)784-3700 FAX(401)784-3710, CONTRACT A $�_if .. Page . 2 9 ` S E - PROGRAM � THIS CONTRACT 19 ENTERED INTO BETWEEN RISE - y CLC-RCS ENGINEERING AND THE CUSTOMER FOR WORK icr ENGINEERING DESCRIBED BELOW r CUSTOMER PHONE - DATE Clients Joseph D Dunn 'a,e c-e.y t� i H I Lrl_e S i' bpi N 14 (781)331-0806 11/10/2011 125591 SERVICE STREET BILLING STREET (9 19 U V 1 70 Elliot Road 73 Broad Reach#m41c DP SERVICE CITY,STATE,ZIP - BILLNG CITY,STATE,ZIP ��� ®fl0 �� ± - - Centerville,MA 02632 N Weymouth,MA 0219 JOB DESCI$IPTION RISE Engineering will apply all applicable,eligible incentives to this contract: You will be billed only the Net amount. Currently;for eligible measures,the Cape Light Compact offers 75%incentive,not to exceed$2,000 per calander year. - e ;$1,497.50 r WE AGREE HEREBY TO FURNISH SERVICES COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF **-*Four Hundred Sixty-Five 8t 181100 Dollars ' $465.18 UPON FINAL INSPECTION AND APPROVAL BY RISE ENGINEERING.CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL INTEREST OF 1%WILL BE CHARGED MONTHLY ON ANY UNPAID BALANCE AFTER 10 DAYS.SEE REVERSE FOR IMPORTANT INFORMATION ON GUARANTEES,RIGHTS OF RECISION,SCHEDULING,AND CONTRACTOR REGISTRATION. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY,BLANK SPACES j q' 11 1� AUTHORIZED SIGNATU E-RISE END ERING - - CUSTOMERACCE ANCE NOTE THIS CONTRACT MAY BE WITHDRAWN BY US IF NOT EXECUTED WITHIN DATE OF ACCEPTANCE ACCEPTANCE OF CONTRACT-THE ABOVE PRICES,SPECIFICATIONS AND CONDITIONS ARE 3_0SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO DO THE WORK _ - DAYS. AS SPECIFIED.PAYMENT WILL BE MADE AS OUTLINED ABOVE. i °Fz r Town of Barnstable *�errSr #ff Expires 6 monl ra i, e Regulatory. Services Fee BARNSTABLE, Thomas F. Geiler,Direotor Mass. i639• ,�� Building Division ATFb MPS A -Tom Perry,CBO, Building Commissioner , 200 Main Street,Hyannis,MA 02601 www.to .barnstable nia.us Office: 508-862-4038 Fax: 508-790-623.0 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint o Map/parcel Number Property Address [`Residential Value of Work •15a�2 L a V Minimum fee of$25.00 for work under$6000.00 F Owner's Name&Address S - Contractor's Name J &-tv -u.5 { j Telephone Number V � ' Home Improvement Contractor License#(if applica le) Ayq ❑Workman's Compensation Insuran a �V K� v Ch96k one: lam a sole proprietor ❑ I am the Homeowner -PRESSPERMIT ❑ I have Worker's_ Compensation Insurance -Insurance Company Name DE:C 2 3.2008 Workman's Comp, Policy# TOWN OF BARNSTABLE Copy of Insurance Compliance Certificate must be on file. . Permit Request(check box)L/Re-roof(stripping old shingles) All construction debris will be taken to '-myn ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders.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-Ovmer Letter of Permission. A copy of the Home Improvement Contractors License Ts-requiredthJ1,1 SIGNATUR �U�J, - -j IG wz i r' .11 , Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revise020108 L. IYTastiachusetts - Department of Public Safety. aay Board of Building Regulations :ind Swridards ' Construction Supervisor Specialty License License:-CS SL 99138 Restricted to: RF,WS JAMES CURLEY 287 FULLER ROAD:: CENTERVILLE, MA 02632 i Expiration: 1/28/2012 Conmiissiuner Tr#: 99138 ✓/xe:-V�o7,vrao7u�ea�ll �aalzuaetta • _ . Board of Building Regulations and Standards. License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration:-,1-24310 Board of Building Regulations and Standards Ezp�rationT 6/1�2 009 One Ashburton Place R m 1301 Tr# 13 087 3 individual Boston,Ma. 02108 YP. James Curley James Curley 287 Fuller Rd. Centerville, MA 02632 Administrator Not valid without re G4 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations + 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): �) Address: 0)( <013I City/State/Zip: `s� Q o Phone.#: - -`0 `TR Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with . 4. ❑ 1 am a general contractor and I ,^ployees(full and/or part-tim.e). * have hired the sub-contractors 6. ❑New construction 2:[ 1 I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑PI bing repairs or additions myself.[No workers' comp. right of exemption per MGL 12.Egloof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp.insurance required.] "Any applicant,that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. if the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA fo overa a verification. I do here -certify_unde th ain an enalties of perjury that the information provided ab ve is t e and correct. Signafore: Date: Phone#: I o Official use only. Do not write in this area,to be completed by city or town off[ciaL 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#: A 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 fore aim en a e nn a oint ente nse-a3=mclun=the le al re p resen-tative�-of a=decased� io-.er-or_the-_�__. — - g g g g J rP g g P mp Y 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 maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to.thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone-and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, ILIA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 11-22-06 www.mass.gov/dia r P,1 Town of Barn-stable Regulatory Services ELARNi y BM MASS. Thomas F.Geiler,Director E161 16 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 ABuilder as Owner of the subject property hereby authorize S(},�VLQa' &rUkq to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) -&A0 S416ire of Owner Date Print N e If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORMS:O WNERPERMISSION Town of Barnstable Regulatory Services Thomas F.Geiler,Director MA & � 16.59• � Building Division PrED M1C1 A - ' Tom Perry,Building Commissioner vir"Aown.barnstable.ma.us Office: 508-962-4038 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 permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned."homeowner"certifies that he/she understands.the Town of Barnstable,BuildingDepartment minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q. Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a fom>lcertifrcation.for use in your community. Q:forms:homeexempt , �,Assessor's map''.and lot number ... �! .-.. .�.. OFT ETO f ASewage Permit number ........................................................ r Z BA"STADLE, i House number0..... / - so Mae& ............ ................................ p 1639. 9� 0 MPY a' TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ............ ........ .....r[a ..!.4.'........................................... TYPE OF CONSTRUCTION .........W.0 o�... .!`!` ............................................................................................ ..................../vu.i ............../...19. .� TO THE INSPECTOR OF BUILDINGS:` The undersigned hereby applies for a permit according to the following information: Location ..`.7.0 .9T..�� �. j. ...�'�.v�I� ,��........ .1* }11o...s.................................. ................................... Proposed Use .. .........A...��� , ...��O1rA.......�Ufa...L�s1�.. .�........ Uwt t� 7J Fire District ... � ��,���2„" CAE;c u•!,��•e Zoning District -.-.—..-. .....:... ...........\.........I................................ Name of Owner ...R.ob? .�r�e 1 ;?1.tU .Address .7� ��e �� ........... ......... .�.......................... .9. ................... ow v�rr Name of Builder S.P.Vqe...................................Address 50 -' Name of Architect e.1 °i'p',.................. ............. .............Address .................... ...:................................................. Number of Rooms .....:...................../ ....Foundation 'Yd n .h......c.............•... .......................................... ........ .....,................. Exlerior �e� �e�a, J��,r+r�Fs 19... .. Ic�1 Cxis�'�v t� ���rc� Gvl!�0��� ' ........4,fo� ....!,)... dlcGG,�js �aq .......................Y........... ...... ��..................�..... Roofing ........... .............. ......... .. / FloorsrJ v.......�3��aDL°o.�cr .. /F��.. Pgr�rc�Es..........lnterior +....Q �^..r� ucl.....:� .. .w, •.s.n: .t............... 1 z Heating ..................... . ..ILN...)e.............................................Plumbing �4!.P.N..`��...................... ..................................... 6/ I QQ Fireplace .................. ..� ...............................................Approximate Cost ...........,�'7�� ................................ Definitive Plan Approved by Planning Board ------------------------------_`19--------. Area �°Z............................. Diagram of Lot and Building with Dimensions Fee ��.' / C ....................... . ................... SUBJECT TO APPROVAL OF BOARD OF HEALTH or qV � D G i 0 r OCCUPANCY PERMITS' EdL rlIRED,FOR NEW DWELLINGS;; t ' I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Namef /f/.1... !./� f �! .::........................... v ,Construction Supervisor's License .................................... A r r HOLLAND, ROBERT C. A=248-054 No .... . . ... Permit for „Build GARAGE ADDITION �� ` Single 'Family Dwelling ............................................................................... Location ...70 Elliott Road ............................................................ Centerville .................................................:............................. Owner .......Robert -C. Holland .......................................................... Type of Construction. Frame ... ..................... ............... ............................... Plot ............................ Lot ................................ Permit Granted November 5, 19 85 Date of Inspection.....................................19 Date Completed ...................I...................19 1�VAssessor's map.and.lot number ... � — ��'v� ���:.. SEPTIC SYS'TErtIIUST �E Tr DK&6L'' INSTALLED lid MPLA `N c� ewage Permit number :..... WITH TITLE 5 S111, IA 90 �" STABLE, i House number .... a . �dVIRONMEINTAL.CO® A� 9OO M6 q 0� 5VS �e • '>TE'p,MPy a' TOWN OF BARNSTABLE BUILDING ' INSPECTOR • • APPLICATION FOR PERMIT TO:...:........aJ..,ilG!........ ....q��.!�..'.4!'�...................... c� TYPE OF'CONSTRUCTION .........l.)o o.....................:..........�a van.E...=......................................................................................... ��....:. ,9.r TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ...........7.0.. .��.!.41T... �?...�. .. .til Y �}����. ...... .�. \11a5.`':....................................................................... Proposed Use ..��.. rso,..a.. Qor�c��i.`1Q}..? .... �v+�p�Ol�� ..............................:.................................................. Zoning District ......`.� .....Fire District ... ..`..C7S,.e c......,t j„g•..•...•••.•••..•.. Name of Owner „Rower\ �'..: `.ld�t ......:..............Address .70 , a .../. .evc%v.0 !(� Ow tier • Nameof Builder t................... .s!. ...................................Address .................................................................................... Name of Architect /l14e' �W"ie�.:..........Address S ^'t�................................................................. ....................... .. .................................... Number of Rooms .......................... ....................................Foundation ...`r`a..X.. . ........................L"atcre/ ....:............. Exierior Roofing �,�rci GJ' .....�lt?Gu1...�� �i/U/c(/ jsiwQ Floors U........ tOD � � �I S •Interior � 514-,Cj. ............... Heating ............... .WaK.e...............................................Plumbing .......................WOe 40--................................... Fireplace .................. '.'. .e........................................:...Approximate Cost ...........1.�7��'........................ .................... Definitive Plan Approved by Planning Board --------------------------------19________. Area O.............................. Diagram of Lot and Building with Dimensions Fee15�' / S SUBJECT TO APPROVAL OF BOARD OF HEALTH �a �aX rTv Yj�Sgt" ue 0 1, N, -Ae-k; -V-r1oc.N�,�, OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. / Name ............................ _ w Construction Supervisor's License ...:................................ HOLLAND, ROBERT C. I^�s BUILD GARAGE ADDITION No ..... Permit for .................................... Single Family Dwelling .......... ............................................... Location ....7.0...........Elliott........ ...Road .d............................ Centerville ............................................................................... Owner ......Robert....C ...Holland.............I................... . . .. . ...... . . .... Type of Construction ...................Frame....................... ................................................................................ 4 Plot ............................ Lot ................................ November 5, 85 Permit Granted ..... ............ 19 Date of Inspection ....................................19 Date Completed 19 36, .......... W: ZS kn > M M X M v k 10-Oo�.11Qt11 �w�. t '��bJ►'A IONI�fi 91 NA1{1i 1 1� !A'O ,NI —I- olo el r f. , f rreTa7e1 4w%*%. .a,h,o, '`''m t—j" 'K1 w"o, OQ 1-0.5 P-t on 1--t QL � k I NOYribh.A�i� -'w tiMN•0.10 VO(h r. �1 je a b.�:.e� 6u���k3 C ��`.a.btJ °L xorfl vvp�►o•s�y'� -PLU a M"�Q i f .'_ __.... .. _......---.�._____. ,._^.'BM�Op'ri{�Y1 �J'w7►i���'f�9!�rA���; � 1 Pr►[ p Q i�►� M 9/ M