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0088 HUCKINS NECK ROAD
��� � � - 't� �i, ;Sq .�'; � ��,#� d .,F Ft +. e O �`� r�; � ' � P�� •` � 3�:r�� � t.^1. .. , tom,. .. ..a' .. ....;.,S¢ � .:'.., a _ ��. .y +o r. i.a.- e t' 'ay" � G' s. � Fti � ti <Y-� a a t. �- t ;r � � _ ,.c ,. _ . ,. ti. ... . �, .. � ;4 _ - - 4ig � - ' � ., I 6 � .. }� !1 S 1 _ - 6,. �. � .. _. � a .a i} 1 �' C .. �� 5 S. ,; ',, .. ;' , r �. ,i. _. � , � , _ _ , ,. - . . ,. ' � �� 3 -. '.� .. :�. 0 � - � .Q - 1 .. u ... .. .. .. .. :. .� .i -. - �I' W' ? . Application number ........... - - �� Fee .... .. '........:..... ............... ... ...................... KM Building Inspectors Initials....... .. .......................... + s�9� A♦ 11 Date Issued..............�. .5 ....................................... 12 Map/Parcel..........0. �.._..01. 1................... TOWN OF BARNSTABLE T EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: 14 u-c k i,�_5 d�ick -7�F i-L) NUMBER STREET VILLAGE / Owner's Name: a y W LL>-eo_-L Phone Number s"PS_ 77S- Email Address: Cell Phone Number Project cost$ 3,000 Check one Residential v'.. Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize 4f to make application for a building permit in accordancjW786 CMR Owner Signature: l�Ji ��°'� G .�cv�c Date:- �. TYPE OF WORK ❑ Siding LN" Windows (no header change)# ❑,- Insulation/Weatherization ❑ Doors(no header change)# Commercial Doors require.an inspector's review ❑ Roof(not applying more than 1 layer of shingles) Construction Debris will be going to O%Jk�n '111 1 "1F;e-T Si_Q-V010 CONTRACTOR'S INFORMATION Contractor's name Home Improvement Contractors Registration(if applicable)# ) L1 (attach copy) Construction Supervisor's License# (attach copy) o C©YA cftsv 0 W J Email of Contractor C_O W ge'Mo e number, % ALL PROPERTIES THAT HAVE STRUCTURES OVEIWS YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT. YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER....................................................... .. L *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent Fuel source being used LP tank 201bs. or>Yes No ,if yes,a gas permit is required. Natural Gas Yes No , if yes, a gas permit is required. If food is being served at_your event please obtain a Health Department approval between the hours of 8:00am-9.30 am or 3.30 pm-4.30pm. Commercial events may require Fire Department approval, *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date . APPLICANT'S SIGNATURE Signature Date All permit applications are subject to a building official's approval prior to issuance. 1 1 The Commonwealth of Massachusetts r 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): ��-'J- `� coop vak�yz) Address: �g �h:tnsrps L.jPrw , City/State/Zip:(S2yokyry \F—�' p:?,67S2, Phone Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 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 g• ❑Demolition workingfor me in an capacity. employees and have workers' Y P h'• $ 9. ❑Building addition [No workers'comp.insurance comp.insurance. required.] 5. ❑ We area corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I.❑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.❑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 anew 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. 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 for insurance coverage verification. I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct Signature: Date: OP' " 1 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. 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 gnd.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"everyy 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 cant'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 to any business or commercial venture (i.e.a dog license or permit to burn 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,MA 02111 Tel.#617-727-4900 ext 446 or,1-877-MASSAFE Fax#617-727-7749 Revised 4-24-07 www.mass.govfdia 4a .. Commonwealth of Massachusetts }1wIF Division of Professional Licensure Board of Building Regulations and Standards. Constrvoti'bri'SUpervisor.. x ` CS-0098§7 Y F}pires: 12/23/2019 JEFFREY M CONRAD . 535 PHINNEYS-LN r' CENTERVILLE MA'02632 ` Commissioner f 1� (90/!7/J70gCG�2C!/c•L'�,��Cli-i2C�C!-iB��i — __._. ' Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation _ 24f 05/08/2021 10W Washington Street -Suite 710 JEFFREYCON� " Boston,MA 02118 D/B/A CONRAD F3EIVtODEtLf1IG: JEFFREY M.CON 535 PHINNEYS CENTERVILLE,MA 02632�• • Underseem-tary t valid without signature _ f ! t t y Town of Barnstable *Permit# "'r ryes 6 mont ro sue dat RNgulatory ServiceseeBARNSUB <� MASS.Mg, Richard V.Scali,Director i6 39. .�� 07 $Auilding Division u� ofna,Building Commissioner ��`P 206 Main Street,Hyannis,MA 02601 _ 1 � www.town.barmtable.ma.us Office: 508-862-4�3�8��� Fax: 508-790-6230 EXPRESS PERAUT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number a� Property Address �O rl`,�1! and 1� �G1L O� CeKA-ep%;Ae... N\/A- C'r;ZJG:S-2— ``residential Value of Work$_—lF 6-0- 06-0- 0Minimum fee of$35.00 for work under$6000.00 Owner's Name&Addressm A4�_czVN M L il_� wobkr3 V`. Contractor's Name Telephone Number,�568-29 ej V `? Home Improvement Contractor License#(if applicable) ��Flo -7 It Emai1�OW ctva �2'e�o �i Svsc ��m CiA�I Construction Supervisor's License#(if applicable) gy ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor I am the Homeowner I have Worker's.Compensation Insurance Insurance Company Name/ S cr—t/Ate tm a Workman's Comp.Policy 5-Oo 5-O 16 I N3 V-7 A Copy of Insurance Compliance Certificate must accompany each permit. 1 Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) Re-side Replacement Windows/doors/sliders.U-Value �� (maximum.32)#of windows #of doors. 'Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Im rove ent Contractors License&Construction Supervisors License is r uired. r* �l SIGNATURE: t QAWPFII.ESTORMS\building permit forms\EXPRESS.doc 01/25/17 �L r Town of Barnstable Regulatory Services Richard V.Scab,Director - BuDding Division. Paul Roma,Mdkbng Commissioner 200 Mum Street,Hymmis,MA 02601 www.town.barnstable.ma.ns Office: 508-962-4038 Fmc 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, 14 U' ,as Owner of the mblmt property hereby authorize m act on my behalf in aU matters relative tD work authorized by this binding pem3 t application for (Address of Job) **Pool fences and nlarms 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 Y1910re of App cant A-ge,L n- �� Alt,�C Cwoet Mr f0 Print Name Print Name Date QYORM -OWNERPERMMOKMIS f 07/07/2017 14:09 FAX 5083942524 DICKEY INSURANCE Q 0001/0002 From:AIM 07/07/2017 13-42 0118 P-0021002 a`O CERTIFICATE OF LIABILITY INSURANCE °"a 10 no1°17 THIS CERTIFICATE ISSUED AS A MA TTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DO NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND. OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS C FICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE R PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT: If the rifficate holder is an ADDITIONAL INSURED,the poTicyfies)must be endorsed. If SUBROGATION IS WANED,subject t0 the terms and condl ions of the policy,certain policies may require an endorsement. A statement on this certificate doss not confer rights to the certificate holder in ieu of such endomement(s). PRODUCER 04971-001 cT Dickey Insurance Agency Inc 4971/1/452 Dickey Insurance Age ncy Inc OM Ed)-. I a Nn: PO Box 39 rA sexvicee thefairwwagency.oom Dennisport,MA 02639 Associated Employers Insurance Company 33758 VMRED INSURER Jeff Conrad Conrad Remodeling 535 Phianey's L MURMILE Cosee:ville, >� O G3'J COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY T THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITf STANDING 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 COI DITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 'TYPE OF SURARM 110 POLICY NUNRER LIMITS I GENERAL LIABILITY EACH OCCURRENCE S COmmERCtAL G ERAL UAB UTY DAMA rT®PREW c OCCUR MM EXP(Any am person) s PERSONAL 8 ADV euuRY i GENERAL AGGREGATE S EN'L AGGREGATE LIN r APPLIES PER: PRODUCTS-CAMPIOP AGG S _ ucY R oc AUTOMOBILE LIABILIT f CON BOVEO SINGLE LWT S ANY AUTO - BODILY NUURY(Par person) S - AUTOS M, AUTTOWNES SODILY UQURY(Par accidanp S HIRED AUTOS AAUTOOSVrlIED PR GE S _ I E UMBRELLALJAe OCCUR EACH OCCURRENCE S EXCESS LIAB CLAAIS MADE AGGREGATE S DEDRM NTION S S •1DESS X N&MwS CEYLII E L EACH ACCm N s 100 000 00N/aA Y WCC0D01614 -SOD 6/2 /2017 612W1 EL DISEASE-EA EMPLOYEE S 100o0o.OD cryOHP w EL DISEASE-POLICY UTA T S 560,000.00 DESCRIPTION OF opERAiu ims i LOCATIONS I VEHICLES(Attach ACORD 101,Add'ivanal Ramada Scaadala,H more spaco is rew1rod) The workers compeo sation policy does not provide coverage for Jeff Conrad CERTIFICATE HOLD CANCELLATION Town of Yarmouth Attention:Building 0 vision SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Yarmouth Town Hall THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED W 1146 Route 28 ACCORDANCE WITH THE POLICY PROVISIONS- South Yarmouth.MA 02664 AUTHORLOM REPRESENTATIVE 9)19W2010 ACORD CORPORATION.Ail rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Massachusetts Department of Public Safety Board of Building Regulations and Standards License: Construction Supervisor - JEFFREY M CONRAD 535 PIMNEYS LN CENTERVai E MA 02632 -aTmissio!tef , -^�ifdLiCR: 12/23/2017 OWtce,sa ✓�e�,pyt�raxtoai��o�t7�i�.tsaclurx�/� - 1------ s Of i<A Affaft&B •.,,Uka. - HOPE 4APRO19EMENT TRACTOR TYPE:lravidW Registrauan varid for hKwwU8l use a-- __R r'.,.' bye the °idy 124074 _ p Office Of Corgi O��m U JEFFERY M.CONF1Ap " :i 19 10 Park p!�-S�w-W Sf70 EkIshiew Regulg4pn D/B/A CONRAD .' - A }-> Boston,MA 02116 JEFFREY M.CONRA&r- - 535 PHINNEYS : CENTERVILIE,MA 02632 Undue . Not vaid wi&Ou>t si9ralture yj 27w CowwarmeaM ofMassr,diusetts Department oflud-z�strial Accidents 600 Wasbarrgton,street Boston,MA 02HI mviemmngarldia Wurke& Cuinpensafian ice ATL&y=Bmlder-JC�nfractursMecfriciansJPluinhers Applicant Iufw=tinn Please Print E,e alp 1V!'llIlP(Saline ga oalTnc dual `� C TS�'p� / V l i C-0yu�r"AAO Addre.,=,�3 Cit /St ltr v zkVN a �R- c�6�2_ 7 Are nanemployer?.Qteclsthe appropriate ba= T of"reject r 4. I am a general contractor.and I P ] t mod}- L I am a employer u ❑ 6. ❑New c onsfx c box employee;(fib andforpart-fime)� 1�elsired.tixe salt-corirt�actas 2.❑ I am a sale proprietor orpartaw- Tisied oatlse attached sheet 7- ❑Remodelsng ship and leave no employees , These sub-conlaac-tars have S-,❑Demalifiba worUng Rw nn in employees andhare walkers' � �� 9. ❑S,uildiag addttl�aa INo vupdm a camp.fi e camp.RM= required-] 5. ❑ We are a cotpomfim and its 10❑Eleoff i al repairs or a,d&fioas. 3_❑ I am bomemmer doing aid work ofFcershave Wised their 1L❑Phnmbiagre-paim ar additions. tion snpsel€[No vrotSoecs'corer- right of per MGL. ]?.❑Boafrepairs insurance required—][ c.152.§1(4�and we have na employees.[No woA=s' 13-0 Other W,1W cow. conxp.ims=ce required) 'keys c-!:at ched=boa ffl mast else ffi a the sec�aa bcIa�rsbatdag aiea woskea'compeasafiaupaTsccy i aa_ �Dn78[7wiIlEIS W}Jo sahogt dsis sfSda<<u`ia :g deey ax��7m�elfwa�c andebffiIm.E autsideeoatacmrsamst.submit a mere affidaeft mdicsflno Mfli TCaa�ac[nts�R checY s bmc must sttadied=addi6nnal sheet shinda 9 iensme of lbe sn6-cat wtcF and state vrhediet arnatftse eatttiesh employees.If the sab-c=tractmsbz7aeaplayea%fiLeymasI pm-idetheir wmimrs'romp.parkymmabm I a ais enfprayer flea ispraucaTirrg ivarkers'camlrertsadarc hz=ran w for arty employees $etoiv is fhepv cy and jub site IR,f•OlTlratfOlL . I�ffi6f:CaglpaIIy'3�3mE;�,ciSt�Gt YT T�-�l_ ��1'Ill�Ocke.Q`S � we�o VVe ' Policy or Self-ins.7iC. llJ CL- ',,T-c7 t4 FxpiiouDafe: �( I JCL e v �Job e Address: '�V5 'YWSIL 0 IVl& 2-6 3 2- At#ach a copy of the workers'compensafionpoacy(ieclara4ion page.(shoving the policy munber and e=pu'ation date). Failnre to secure coverage as requiredunder Section 25A of MGL a 152 can]lead to the imposition of csimimai penalties of a fine up to$L,SI}0:4a 2wVGr one-year imprisonment,ss well as civil penalties n the form of a STOP WORK ORDER and a fug of up to$250-00 a day against the violator- Be adsised that a copy of this statement.maybe forwarded to tIM Office of InestFgations.of the DIA far i'stTMcJff coverage y-erifrcation I rta ri�-c*iy tha pis and par a.f ctux3' a�friattits irc}armatialt prmzrid abarw is true �d correct Phone 02ki L am raft}. Do ant aurae in f ds area,fa be cwnpfetad by city artenii aic ct City or']'owu: PermtMicense* Lwxing Anflhw4(ca de one): L Board of Eealth ceding Department 3.QtylTown Clerk 4.Electrical Inspector S.Phmabmg Inspector 6.Other Contact Person: Phone#: Information and Instructions 7.mss arhnsetts Ge�o a Laws c M requires all=ployers to prm&V01IM&=11?e�satinn fmr their emplbyees. Pm3-aanttD this fie,an wgrLV=is defined as"--eRes9Personin.$�e service of another Under Ray ccoitm t ofhfie, a express or zoop d,oral or Written." An Moyer is defined as`pan m parfne�,assp�fion,�P�On or other legal eXray,or any two or male andmcbidmgdie Iegaf relresetiives of a deceased employer,cr the �a"Dint , - Of the foregoing engaged J � However the r 'eiY®r or i�rastse of en individual,part�up,associatoon or ofi�.erlegal enfitY, q °yn n Y�- e o ofthe- owner of a dwcMogbonsebavmgnotmoicth tk=apartments and�xho residestberem,orth c dweMag house of Mother who employs pe$s®s to•do maitIMce,Cajn ,f CFa or repay Work oa such dweIfmg house or on.the grounds or bu ildmg eppu�thereto sbannotberanse of such employmentbe daemedto be an.employer" MOL chapter 152,§25g6)also sites thA-every state or local licensing agency shalt withhold$te issuance or rmeFFal of a Hcense or permitto operate a bU hess or to construct bw1diags-fu the commou�ealth for any applicantw•ho has notproduzced acceptable evidence of cdmPliianmwn tare insurance.coverage required." Additionally,Md chapter 152,§25dM states W&ifb=hie nor�y ofits political subdivisions shall eMter into any con-t ad for the:perfonmsmw ofpublicworkuntil arzxpiable evidence of compiiancewiiii a msrsMccE.. rCTZjr=CMfS of dais chaptex have Be=pres in file g.a3b oayf Please fill oht the Worker'compensation affidavit cmnple#rly,by chug fheboxes chat apply to your situation anti,if nmessaq,Supply snb�ofor(s)name(s), ad&ess(es)End phone—ber(s)along with their=t[Ecate(s)of�ihanfbe msvi-ante. Ljc i Lia?MY��es gEC)or Li itedLiab�ifyPait=ships(LU) i no enplflYe�s member or parba=ss are not rbquied to callY vmzbc &compensatian fi sarance- If an LLC or LLP does have employees,apolicy is regnned. Be advisedtbatfius affidaykmaybm m2=i�d to the Depart nmt of Industrial A=d�for conftmadon of firm ce coverage: Also be sure to sign and date axe of tdavit: the affidavrt.sbovld be•ret=ed to the city or town ti>at the agpliraiim for die peooit or license is being rnqucstA not the D epartmeut of Ln3iistng A=dmb- Sluould.you have any questions regaidiag tho law or ifyou are regahed to obtain.a Workers' compensationpolicy,PleasecalltheDepmtnez3±attheunmbealistedbelow: 5e1f-m nl-,aea¢rrpaniesshouaIdeatc:rtheir self-mgrancelic=senm beron.fbeapprc n s li= City or Town Of cials - r Ple as a be sate that rite aflidavit is complete and F d legibly. The Department has provided a space at file bot 3m of the affida4k for your to 01 ourt in the event the Office oflMvesdgations has to contactyoa regarding the applicant Please:be score to fM in the p=�olFllicense M bet which wM.be used as a reference nimber la-addTtion,an applicant that must submit multiple pezin ns in any appht;E6 any given yew,need only srJbmit one affidavit indicating cat policy i afom3ation.(ifnecessny)and under"Job�e fi�rese tie applicar¢should write"sII loins in (�Y or tow ' copy offhe-affdavit. athas beet officially stamped orma>iredbythe airy ortownMay be provided the n)_ A applicant as pmofthat a valid affiffir&is on file for faf= pe�ifs or hceuses_ A new affidavitmust be filled out 6a.eh year.Where a home owner or citizen is obtaining a license or pe=it not mlated in any busihms or CoMM=ial vie. . e or permit to bmn lmves etc.)said pexson is NOT xegaked to complete this affidavit Cie.a dog licens Ibe Owe ofIMyesfigations wouldlike,to.flank youina&mce for your coopwa ianand sbou lAyouhave anygacsfions, please do notheshaiEto give us a caM The Deparime f s address,telephone and fax m=Lber - CGmmMTMjt1j of Massach ' Depaxfmmt t}f �GCt�0Il1 Office @f TnVefi.0a Fax#617 727 774 R.evised424-07 ,mazz DVARR. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel G" Application Health Division Date Issued 12`7 IS Conservation Division Application F Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address f 9 14ccck ,n s -ecg ad Village Owner 'M i 1x,;a rl A, wevct Address s Telephone 77 S' Permit Request _ 3�,s�fa ti"� , wd1��-�Z J lQ.S tun, AM"e Ccell,65, y/ils 1Nl r-F= Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuatiot XG 3 1 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Ck Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑ Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq _ Number of Baths: Full: existing new Half: existing new- Number of Bedrooms: existing _new -- cn Total Room Count (not including baths): existing new First Floor Roo Count;► cm Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑Other rn Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new ,size _ Other: t 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 41`C�04 S fi 1�-,CtL Telephone Number Y 3 7 1-z Address 11 4 £�6 Sr License# 160`t/2 tc.Cl Rir4, Otlk o--wj Home Improvement Contractor# l tI�lylz Email 14iWe 0 kocil SaLmlComT, n e T Worker's Compensation # tic-tco-(cv6�7'tR-�6Kl4 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO Ii1,14� SIGNATURE DATE ` FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED 6 ' MAP 7 PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: `. FOUNDATION FRAME INSULATION K FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL QUILDING= DATE:-CLOSED OUT ASPOCIATION PLAN NO. . , �Jl7C �fl/%71')C=.Jiff11%ffl�� r�^:'l�Cf,iiflC�dG.iFl� � . 1_ Office of Consumer Affairs and Business Regulation ' , 10 Park Plaza-Suite 5 170 Boston,Massachusetts 02116" Home Improvement Contractor Registration a Registration: 144412 Type: DBA Expiration: 1014.12016 Tr2 260275 •. ROCK SOLID CONST. ° MICHAEL ST.ROCK —— - —----— --...- P.O.BOX 1981 FALL RIVER,MA02720 ' Update Address and return card.Clark reason for change. ' u Address —Renewal —Employment "_'Lost Card 777. ;Z' OMcrof Comamer.anairss aosisess Regatan.. _ License or registration valid for individul use only ' 11OME1M?ROVEMEN7 CONTRACTOR - before the expiration dare.If found return,to: tom Registration: 1412 Type: Office of Consumer:affairs and Busihess Regulation : r1 ' Expiration: 1014re01S D6.t 10P2rk Plaza-Suite Sl70 - `a. - Boston—NIA 02116 ROCK SOLID CONST. - MICYA?L ST ROCK r •' , 207 F NT ST 93 . FALL R!VER.N.4 02723 _ Cederse,mmry Not valid without signature n--- TW Massachusetts-+Department of Pubiic Saiety Restricted To:CSSL-WS-Windows and Siding Board of Budding-equiations and Star,Cla f ds CSSL-IC-Insulation Contractor Construction Supcnisor Specialty License:CSSL-100412 MICHAEL A ST DOCK =c c 119 EDDY ST Fall River MA 0T123 yv $ ` t +,, _ . Failure to possess a current edition of the Massachusetts- State Building Code is cause for revocation of this license. rxpifatic; r Commissioner 09/11/2016, Foy DPS Ucensing information visit: www.Mass.Gov/DP$ r � L tt •. , • - ' e i a I1/9/2015 9 : 21 :56 AM 8620 03/03 ,aco CERTIFICATE OF LIABILITY INSURANCE `MM)°°mr"' .� ,. ovosnm s 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 pollcy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require anendorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsemerd(s). PRODUCER 00723-001 IMACT , Stafford&Company - �g, e,E�,. (508)674-3595- •Nc.: - 1000 North Main Street Fall River,MA 02720 INSURER A: A.I.M.Mutual Insurance Company _ 133758 INSURED Michael St Rock _ INSURER Rock Solid Construction INSURER C: B 0 BOX 1981 - INSUR -. . Fall River, MA 02722 ItISURER S: 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 l. - 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 TYPE Of INSURANCE. INSft POLICY NUMBER _ PMA YYV IYYY'/(MAD LIMITS - s GENERAL LIABILITY - _ - EACH OCCURRENCE $ COMMERCIAL GENERALIABILITY DAMAGE TO RENTED- $ PREMI S orc r en al CLAIMSMADE 17 OCCUR , MEO EXP(A.ry one:Person) S - r PERSONAL&.ADVBJJURY. $ G ENERAL AGGREGATE '$ ENL AGGREGATE LIMIT APPUES PER'; PRODUCTS.COMP/OP AGG S , AUTOMOBILE LIABILITY. - « NED SINULEDMITS: a r cci i i ANY AUTO 9Gq!Y.INJURY(Far person) $ / ALL GYJNED SCHEDULED. BODILY INJURY Per accident $ AUTOS AUTOS Ssif t ) It1REO AUTOS NON-0`NNEO I - 0 R MAG_ i ccWen[ $ AUTOS (For UMBRELLA LIAR OCCUR EACH OCCURRENCE S EXCESS LIAR CLAIMSMADE ' AGGREGATE� $ ypR�DEERD cpMpERN`pETNTIONN ST.p.�Lr S AND EtAPIOVER3'L1N811QTY /N • d X TORY LtM1T5 �Oh:. Y ppR�pRIETORIFARTNcRJE7�CUiPIEY NIA VWC-100.6017749.2014A' 8/2112014 812112015 `L°AC;yACCIDENT .. $ 100,000.00 A ��rICER/Mc,,BER_xCLUD_D,, (i J . (mandatory 1p�nq N11�N}qq - C! DIS ASE•EAEMPLOYEE S 100,000.00 DESCRIIR&oMERATIONS.below �• EL DISEASE.POLICY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attse ACOROl01,Additional.Remarks Schedule,B mom space Is required) - - Y - The workers compensation policy does not provide coverage for Michael St Rock CERTIFICATE HOLDER CANCELLATION Town Of Barnstable 367 Main Street - SHOULD ANY OF THE ABOVE DESCRIBED POLICIL=3 BE CANCELLED BEFORE Barnstable,MA 02630 - - k THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN i a� ACCORDANCE WITH THE POLICY PROVISIONS. ' - AUTHORIZED REPRESENTATIVE - - 01988.2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD 4088 i T Town Q Barnstable RegWatory Services MANS 8' x ki6aid ScA Director; ' BiWdi�g division Tom Eexr'y,Building CommSssioner 100 Main Street Hyannis;MA 02601 WWWAoWn.barustable.ma us' Office: 50.8-862-4038 `:r� : : �. - flax: 508-790-6230 ppprty C7wner,Must, Comoete`and:Sitgx :7['his Section F If UsMI A wilder 1_+ pp��q Ra�� �`y�.•;,J+.Y. .b y+s u e n ,. + E*Ni0�! I, ot Y C I 01ner,Qf the`subjet property k erebyauthorize /�vC k- ��� 5n 5 G GI7' to act on be �. ,. .. . ,��.. rr?Y a half, iu,aU matters.rekt ve:to,work authorized by this building pe.m it application for: `Pool fences and alarms am.;the x`ziespons ty of the ppl cant Poc]s are ilot.to be filled'or utked;before fence 1s:installed'aud all�fiial . inspections are.pprforrned;aud accepted. Signature of.C avner 4. .. �, -Signat of`4pU6ant i e-j 0- 6Au)C)e,)-r( PY.{,i t Narrie _ .. t Priat Name � - y Date Q:F0RMs:0wN'MZFMUassi0NPoois ..h „ The ComkonwealthOfMassachusetts PrintFocm ` Department of Industrial Accidents -- Office of Investigations I Congress Street,Suite 100 Boston,MA 02114-2017 a www.mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricions/Plumbers Applicant Information Please Print Legibly. Nance(Business/Organization/Individual): STru.c� Address: !! 9 f�l - 5 City/State/Zip: wLl 4 Rr1.4 G<•7, Phone#: p 3'-7 tL` Are you an employer?Check the appropriate boa: Type of project(required): 1.® I am a employer with 3 - C ❑I am a general contractor and I full and/or = have hired the sub-contractors 6. ❑New construction employees( part-time).. 2.❑ 1 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' insurance= 9• ❑Building addition coin [No workers'comp.insurance P• required.] , • 5.❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doingall work officers have exercised their 11. Plumbing� g repass or additions myself.[No workers'comp. right of exemption per MGL insurance required]t' c.15 12,0 Roof repairs 2,§1(4),and we have no + employees.[No workers' 13;❑Other comp.insurance required.] •Airy applicant that checks box#I 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. koutractors 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-eonttactors have employees,they must provide their workers'comp.policy number. c I am an employer thatis providing workers'compensation insurance for my employees. Below is the polieyand job site information. _ . r Insurance Company Name: Policy#or Self-ins.Lic.#: UX-/oc-(0 i'771q-J-0I Y A Expiration Dater Job Site Address: 0 Y L 4 C It i N) Al eGl( 12 City/State/Zip: Cis Caw Ile-4& UP 3L , 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 MOL c.152 can lead to the imposition of criminal.penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. 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 hereb certi under the and enaldes of .eeijury that the in orma8on provided above it true and correct Si tore: . _... ..._ ... - .._. _. - -- - �- -----Date II Phone#: /Z/ F 3 7f'-�1 t. Official use only. Do not write in this area,to be completed by city or town offuiai City or Town: PermitUcense# Issuing Authority(circle one): , 1.Board of Health 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector 5.Plumbing Inspector < 6.Other - Contact Person-. Phone#: y r `rows 'of Barnstable ' :Regulatory Services P�� Or- BARP�STABIE 9 MA_q& 8 Richard V.Scali,Direclor ,r t rat Building Division 22. Tom,Perry,Building Commissioner 200 Main Street,Hyannis,i1A 02601 AwNY.to►vn.barhstable.ma_us 0-11lT .� � F)IC-N Office: 508-862-4038 pax: 508-790-6230 Property Owner Must "Complete:.and Sign This Section ,If Usino, ABwdder I, 7YI aA uA- 7k �Lt.��-��c � .�:(� ,as Owner of the subject property. , hereby-au:hon*ze s C IC-- to act.on my behalf, in all matters mlative.to work authorized by this building permit application for v ' � `�� /� L:t�.,.K.4;Lr5- t��-�`-'�".:>- Ir�G-I` L--e..i.ti �. .1 a4....���� /��LL L�•�-Gs .�;,�1 (Address of Job) Pool fences and alarms are the responsibility of the applicant: Pools are not to.be filled�br utilized before fence is installed and aUlin-J - inspections,are performed and accepted: µ Sipature of Owner r Signature of INDPECa-' Print Nance Print Name F . mil / G /U'.-G% �'. - ,, .{• _ �'- - � �;,./ `a� Date - - D _ , ,JAN, 1, 2015 Q:FORMS-OCv-,%T PEnhi]SSIONPOOLS !' I Cd ' Town of Barnstable *Permit# 06 �� rr j„E 6 -S PERMIT Expires 6 m hs issue e `T a Regulatory Services Fee * ansxsTABM 94 r 1 S 2013 Richard V.Scali,Interim Director 16 9Building Division (g,,1141.3 3'am Perry,CBO,Building Commissioner TOWN 0F BARNSTAB�.� 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PEFMT APPLICATION - RESIDENTIAL_ ONLY Not Valid without Red X--Press Imprint Map/parcel Number'5-Z()2Jy Property Address 2 r-1 C Y v-1,S 6L 60 ❑Residential Value of Work$ W,'000 --- Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address rm rs M r 0 L000(j Contractor's Name _ 1`a Ate ry-h CCW r Telephone Number Home Improvement Contractor License#(if applicable) �� 7 Email: C�n,rp s�yv�cc��\��r�,�,• Cc�� Gib--•N�� Construction Supervisor's License#(if applicable) G ❑Workman's Compensation Insurance Check one: I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to F,., ❑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: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improveme t Contractors License&Construction Supervisors License is required. SIGNATURE: Q:\WPFILES\FORMS\ ilding rmit forms.\EXPRESS.doc Revised 061313 CA The Commonwealth of Marssackusetts DYepar'tment of Industrial Accidents a,,Q`ace of Investigations 600 Washington Street _ Boston,M4 02111 wmv.mas&gav1ilia Workers' Compensation Insurance Affidavit Builders/Colon-ctors/E ectricianslPlumbers Applicant Information Please Print Legibly Lazne(Busmen,orgwizardanbdividaal):- AA&ess: ?� �h�-VU ry L.yJ CitylStabelZip: e_w `.�,11 t�z�' c�]:t, Z Dane# £ a - TCI7 <z Are you an employer?Check the appropriate boi: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and i employees(fall andlorpor#-time). * have hired the sub-contractors 6. ❑New construction .2.XI am a sole proprietor or partner- listed on the attached sheet. y- ❑Remodeling hip and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity employees and have workers' [No workers' comp.insurance comp.insurance.t 9. ❑Building addition required-] d 5. ❑ We are a corporation and its 10.❑Electrical repairs ar additions 3.❑ 1 am a homeowner doing all work officers have exercised their ILL]Plumbing repairs or additions myself [No workers'comp- right of exemption per MGL 12.C&1toof repairs itasusance required.]t c. 152, §1(4),and we have no employees.[No workers' 131:1 Other comp.insurance required.]' *Any applicmit that checks box#1 mug also fill out the section below showing their woakere compensation policy imfarmzdm I Homeowners who submit this affidasat indiccatmg they are doing all weak and then hire outside contractors m=submit a new affidavit indicating smelt (Contractors that check this boa mast attached am additional sheet showit>g the name of the sub-ccmtcacton and state whether or not those entities have employees. If the sub-coutractotshave employees,they must provide their workers'comp.policy number. I am an employ yr that is proiidiV workers'compensation insurance for arty employwes. Below is the policy and jab site information. Insurance Company Name.- Policy#or Self-ins.Lic.#: Expiration Date: Jab Site Address: City/StatelTipp: Attach a copy of the workers'compensation policy declaration page(showing the policy number and espirat%on 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 S 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 tlolator. 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 herby ce*rti under the pains and penalties ofpequty that the information prinided abm�e is true and correct Si Date- Phone V _q_O!L� — r_25_?Q R9_7 Official use only. Do not unite in this area,to be completed by city or town offtciaL City or Tomw PerlmitUcense# Issuing Authority(tdrele one): 1.Board of Health 2.Budding Department 3.Citylrovm Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 6 ,y Town of Barnstable Regulatory Services * EAENWASM MAS& $, Richard V.Scali,Interim Director .i6;9 �0 '°tiro 39 Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorizeA���6L—et. to act on my behalf, in all matters relative to work authorized by this building permit. . kdAA (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. 77 at Signature of Owner 4sinef Applicant tom, Con A'o Print Name Print Name Date Q:FORM&OWNERPERMISSIONPOOLS 10/13 Town of Barnstable f Regulatory Services pUIKE TOE Richard V.Scali,Interim Director �. Building Division • marts AEM Tom Perry,Building Commissioner 9 165 ���. 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 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 form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 061313 Massachusetts-Departm:p. t of Pu4,1ic Sa€ety Board of.Building Regulations.and Standards y Construction St net-AiNor License:CS-009857 . -r JEFFREY M CARAD - 535-PHPWEVS LN "N' CENTERVII,LE MA 02632 y r- J''G'c" '/✓J -1 �3 . Expiration Corsirnis.sioner, ry 2/23V2ti t3 6TX1 V11114lral caea-IM.o C illr�s r�r. r�9ell r �L\ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only 30ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: UO— egistration 124074 Type: Office of Consumer Affairs and-Business Regulation Expiration 5/9/.2015 DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 Conrad Remodeling Jeffrey Conrad 535 PHINNEYS;N CENTERVILLE,MA 02632 Undersecretary rot alid without signature