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HomeMy WebLinkAbout0085 HUCKINS NECK ROAD . u IN N x � 1 �kr tk't rx fr'a ^�1 p+` �?• •5, �,' Y, 1' .dai �, rt rl R �.y S { ..5a -• ,-,.z1.,.0.. ,,... _F �," i�-�•,'�hx'r_ Y" Z. Yt ' 7//'p � �. • mac. � i. .._..' .>.,i ,,. .z.� ,,. :�. +� .�, ;.:,. ..... w w, :1:�� �: _ .,, s'a.. :}. ',� ., y,a5. >•... _-.., kvn. ,r;:.-#' .,..., .. � V. � a r �' ac �1 a r}'^;�v .,_ t� �� -- r ,�� i. r •v{' e'8' d. .t�.. B. .E• ..,, ,.,r,.tt, -, n. ?,{ .. �.a',H;;..,a .:T•..:.�+. ;ta. * w. N, s.x'.. {tee ' 3 .."5 't.. i ;�' a w£ *. f'^�`" ....„�', �. : .„„ay..�t,.; t 3? �;i.. t t - � 'c. in:', h :'�$=��',c�.'• {r�' n* YRs N, a � •i7 � `.� 5�. r ��2,i i�4„.u�`����, w t ro•, { r'`'uL„r�i • , a , n L x f K S 4 •e r dl _0110 toot kY AM WAYS tat All F 00 i. °a Town of Barnstable *PermitSq Expires 6 months from issue date Regulatory Services Fee sntuvsrestZ • n 0 i639' � 9� MASS. $ Richard V.Scali,Interim Director (� A Q rfD MA't Building Division Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02�,® 400, www.town.bamstable.ma.us ��0 �?O16 Office: 508-862-4038 �i9� ax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL (9 e� O' Not Valid without Red X-Press Imprint C Map/parcel Number u( / [� Property Address 1 !(,c CK r)v�5° Peck P,6&of CResidential Value of Work$ .5 OQQ ` Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address A V/®L `J bl C ILLS 0(1. Contractor's Name &7l1 Telephone Number Home Improvement Contractor License#(if applicable) L/ Email: Construction Supervisor's License#(if applicable) "Oran's Compensation Insurance Ches.Kone: YI am a sole proprietor ❑ I am the Homeowner . ❑ I have Worker's Compensation Insurance � Insurance Company Name -off�P.t1 /� �1/0-14 Workman's Comp.Policy# We- E —0Z Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to YA61-noiti14 C 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: ❑ 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: Prope wner muA sign Property Owner Letter of Permission. A co y f the Ho Improvement Contractors License&Construction Supervisors.License is req it d. SIGNATURE: Q:\WPFILES\FORMS\buildin permi form doc Revised 061313 Ys ` The E'ammonitsteaM ofMassachrusetts02 . Deparbnent of fndustria!Acciden& Office oflntw igations 600 Washington Street y Boston,MA 02111 vpmv.mass govfdia Workers' Compensation Insurance Affidavit:Bddders/Contractors/Electricians/Plumbers Applicant Information Please Print Legillly Name(Business;D%w izatio�>ni�ndividua1): Address: CitylS.tat&Zip: 7' Phone#: �5_019- 3 61, G 3 Are you an employer"Check the appropriate boa: Type of project(required): I.❑ I am a employer with 4. ❑ I am a general contractor and i employees(full andlor part-time).* have hired the sub-contractors 6_ ❑New constiuctiou 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have workers' 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 I LE]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 comp.insurance required_] •Arty a"b333t that checks box#1 must also fill out the section below showing their woikere compensation policy infrrmatian. Homeowners who submit this affidavit indicating they are doing all weak and.then hire outside contractors submit a new affidarit indicating such. Contractors that check this box must attached an additional sheet showing the came of the sub-cantrwitm and stale whether or not these entities hwe employees. If the sub-coatactors 1mve employees,they must provide their workers'Lomp.policy number. Tani an employer thatisprotfrling workers'compensation itisrerance for aiy eaWtco,ees. Below is the policy and job site information.Inslumcecompanyblame: 1QU1 //t%19_h Ae Policy#or Self-ins-Lie.9: Wt --3 S^39W 006 Expiration Date: Job Site Address: ` �� ����'t RUC i 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 andfor 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 insufance covers -erifica ion. I do hereby cerhfj,udder the ns and pen es ofpetjrity-that flee iriformation pm idr4d abm a is true and correct . 5i Date: Phone#: 5_62 Official use only. Do not write in this area,to be completed by city or town official. City or Town: PermitUcense# Issuing Authority(circle one): 1.Board of Health 2.Budding Department 3.Cityltown Clerk d.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 6 I Town of Barnstable Regulatory Services Richard V.5cali,Interim Director .i639 `0� En 39 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 as Owner o e subject property hereby authorizepzf L►^ fto act on my behalf, in all matters relative to work authorized by this building permit. (Address of Job) **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 Owner S' ature ppli ant Print Name Print Name ho/ko l� Dat 1 /1.ann�.re.nnrwmnnrn�rtoarn�mnnr n ini.� .mil _ Town of Barnstable Regulatory Services pF1HE Richard V.Scali,Interim Director Building Division anxtvs-resra, Tom Perry,Building Commissioner Mass. 9 163q� ��� 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION ; Please Print DATE: JOB.LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be, a one or two- family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt n Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner provisions of th is section P from the prov ( g engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,.particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q-.\WPFILES\FORMS\building permit forrnsTMRESS.doc Revised 061313 '!016 10:42:06 AM PST (GMT-8). FROM: 100005-TO: 15087901414 Page: 2 of 2 C® CERTIFICATE OF LIABILITY INSURANCE DATE`MMfOONYYY) 2/25/2016 j' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS i 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 polity,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorseme s. PRODUCER BRYDEN&SULLIVAN INS CONTACT 88 FALMOUTH RD PHONN HYANN IS, MA 02601 fA1ILo.Exit, 1C,N ADDRESS: INSURERS)AFFORDING COVERAGE NAIC# NSURERA: LM Insurance Co oration 33600 INSURED ANDREI YARMALOVICH INSURERS: DBABEL ISLAND HOME IMPROVEMENT NSURERC: 204 CINDERELLA TERRACE NSURERD: MARSTONS MILLS'MA 02648 NSURERE: INSURER F: - COVERAGES CERTIFICATE NUMBER: 28713782 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. I SR TYPE OF INSURANCE A.DDL SUBR POLICY EFF POLICY EXP INSD WVO POLICY NUMBER MMIbD MMIDD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR t DAMAGE TO RENT PREMISES e axrence . $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY 0 PER' LOC -PRODUCTS-COMP/OPAGG $ OTHER $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident ANY ALTO ALL OWNED SCHEDULED BODILY INJURY(Per person) $ AUTOS ALTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED PROPERTYDAMAGE AUTOS eraccident $ $ UMBRELLA LIAB F]OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION $ WORKERS COMPENSATION WC5-31 S 384176-026 2/25/2016 2/25/2017 PER OTH- AND EMPLOYERS'LIABILITY Y 1 N STATUTE ER ANY PROPRIETORrPARTNEREXECUTNE OFFlCERIMEMBER EXCLUDED? N/ AAA EL.EACH ACCIDENT $ 100000 (Mandatory-NH) E L.DISEASE-EA EMPLOYE $ 100000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ SOOOOO DESCRIPTION OF OPERATIONS f LOCATIONS/VEHICLES(ACORD 101,AddOonal Remarks Schedule,maybe attached If more space Is required) WORKERS COMPENSATION INSURANCE COVERAGE APPLIES ONLY TO THE WORKERS COMPENSATION LAWS OF THE STATE OF MA. This certificate cancels and supersedes all previously issued certificates,only as they relate to workers compensation coverage. ANDREI YARMOLOVICH IS COVERED BY THE WORKERS'COMPENSATION POLICY. - CERTIFICATE HOLDER CANCELLATION TOWN OF YARMOUTH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE , 1116 RT 28 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED 1N SOUTH YARMOUTH MA 02661 ACCORDANCENTH THE POLICY PROVISIONS. • AUTHORIZED REPRESENTATIVE LM Insurance Corporation ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD 28 713782 1-384176 16-17 WC Ashish Botgaonka 2/25/2016 1:38:27 PH (EST) Page 1 of 1 Massachusetts Department of Public:$allety y a Board of Building Regulations and Standards License: CS-105964 Lonstruction Supervisor �: I IVAN V 1VANIUSHENKO 174 UPPER COUNTY ROA[!APT 1-14 I DENNIS PORT MA 0263 >` Expiration: i commssioner 01/0112018 I I I i i A I��VI/V Vt���fic c onsumer Affa s (A usiness Ve bg u"at 16 n 10 Park Plaza Suite 5170 Boston, Massachusetts 02116 Home Improvem0it 3ontractor Registration. Re• istration: 1724.76 j ;,, r > Type: Supplement Card Expiration: 7/2/20;18 BEL ISLANDS HOME IMPROVEME T:' IVAN IVANINSHENKO --- 204 CINDERELLA TER. MARSTONS MILLS, MA 02648 Update Address and return card.Mark reason ff scA CozoM osJn Address [] Renewal Employment E i �/�c�ornriznizaneia�/�o`'C_'�f�rJ:J�c��atcllJ ice of Consumer Affairs&Business Regulation ; License or registration valid for individual use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation egistration 17247g, Type: ! 10 Park Plaza-Suite 5170 Expiration ;7-21,704A' Supplement Card Boston,MA 02116 BEL ISLANDS HOME IMPROWI*ME,NT IVAN IVANINSHENKQ „ 204 CINDERELLA TER;.,:;, .--•— MARSTONS MILLS,MA 02648"Y Undersecretary Vlfidllfut signature v (� 1 - r AuthotitAtion for Work Permit: �1 w 11 � )' X � x , s �; 1 4 - 4 r$ a.0 - 'S a +, r�. t �_.�c,� Ky z ,. uz e,: .�+ i t. - tt�� F RT�T, CC . .' t33 BRUADWAY; ROUTE 99 MALDEN MASK MHUSEITS 0214i� "' i Y t t likOA t82 324 8700 FAX 781 324�5773 � ' rye ,n x ,4 rrr <, u€ x > `$.e fix: nu - . - e 1 1 T - , f b ' - augast a 7016` �' y3 _ " T , a ; v Ii r- ' t k �� e n ';, z " r L ','+ .+Cat r} .. .i s To Whom it may Concern ;, e <P r a: I. � , ,$ 3� 11 - We hereby authorize Bel islands".Home tmprovemenf to pull a work permEt to do; , k V' repairs at'the property we own at 85 95 Huckms,'tdeckRoad„Centerville;MA ',F' 9 9, 3 M1, rf a S ; Please tali if you have any questions at 783 R*4 8700 n a is y ""' tv i Thank you, 4 s § �* .x;' a m r ar = 4$ * q,_ ' J *r 4 z k tr,-p h` .j k RROVIDENT REALTY TR T formally Jackson Malden Realty Truster ' ' a b° ;� _ s �� $ s c ` 1. /:J�� ° 4 a , t s . ,J{f./ s2. l p` t a�ul w D W.Jackson Y r i� 4 fi glky t �} '4 <' f - T(UStee - 14 �` _r _F 3i k, _`xr'k1. r,„ r ..5 f y i ex s A d_. - r . ,� u v yr 'f i d ro � 41 r v , i r' a +r n cry i 6 a : .z a z c c: ar . w. :'€as $i', e r ,, x: 'd r . 4 * 1. r , � t,' t .k F5# Y: & n a a a , Y ki ks i As t t 'A E - r yr, tt +x '�tc '' . - ,+ :a " ,.. i- 1'� .-J .k 3 x x e t k F L F .''e �, ,y 'S y £.i w+r3T V,�, e�} r 11 ..5 f'�t, it'i+ # 5 � 1. 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I. :.:.".sue .I b 7 l a ;k ' i 'r = n.s,, ,. .c- i r > 8,. .. . . a I t .. .. ,3:. r SKMBT.C2801 6081 1 22590 pdf MA SOC Filing.Number 201012897840 Date:9/17/20101:38:00_PM, i9/tiJ2030 M Oo ds PAS 979 409 6139' Klilcr*c:nieeoa,.:1?,C: - ®002l00t; Re&uy of Deeds Page 2 of 2 p ^ BA:61910 Pg l", y , AMBdVDtdENtTOTRtfSf' 4kbtWpSggt oesrs0�p,o. ' PpF?etl B�t=OaaueuaM - t,WwmtLJ�4smkTMs1®og?wv"Raft Tjtw U'tAjwh tiM8lAea Raa&YYtus�.md,sdanoYtirmtda4�Aisguu2R,146�esama�dadriewtdedLo . 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