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HomeMy WebLinkAbout0466 OLD CRAIGVILLE ROAD s '� cP . R ,» :<, . .. . .:. , :j ,d r w . .;'h . . . .., .� 'c r x a•`t�''a dy,;,,' »n'*, '1 .+� .'.� s 5�'R't.` •'a,-+y':a =�k�.�. � 5� ,�=4. +��, .+r'4. 4 +d. t �',. Rs• +r- -c YI '�..`9:. r ai ,� 3. - .h s., ..'`S.r,. � 4 ' �,'�. � �.i-. .f ,k3 pp ..fE 1ra, s v wr' q, ,x .'' �e�' . - �.y } i , .. ��'�r �, ?' j;�.d� �ei..>2.F �z� _,.� � y t � X e �aR •N... ;.= 4 s e n e , •, a .. Y� r!• , F p' , tl c i TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION 4� U Map Parcel I Application #,--�),v 60 05 / Health Division Date Issued 1P, to Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board 416116 a-Ad Historic - OKH _ Preservation/Hyannis Project Street Address Village Owner D Address Telephone Lo Permit Requests - V Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuatio Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family 2"" Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes #No On Old King's Highway: ❑Yes A(No Basement Type: ❑ Full 4Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: �13 existing _new t Total Room Count (not including baths): existing new First Floor:Room Count Heat Type and Fuel: ®'Gas ❑ Oil ❑ Electric ❑Other c) Central Air: ❑Yes QMlo' Fireplaces: Existing New Existing wood/coal st&e: 9-Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: 0 existing ❑ new size _ Barn: 0 existing❑ ne aw size_ w fT Attached garage: ❑existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: , Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Telephone Number C--VTZZai,4j"Pet) X�� Address License# Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE,,,­ DATE C �� �� r i FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION 5)56 o-S 0 Sl3ha z Ax- FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL {; PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING U-ho ® a { DATE CLOSED OUT' ASSOCIATION PLAN NO. . The Commonwealth ofmasscxchusetts -Departrneni of lit dustrial Accidents' Office of Investigations 600 Washineon Street .Boston, AfA 02111 j • www.rnass.gov/dia I Workers' Compensatio snrance davit: Builders/Contractors/EIP ctricians/Plumbers A Licant Znformatiori a Please Print Le 'bl NaME1 (BusinessJOrkmization/Individual): e Address: ' City/Stale/Zip: �� �� , � Phone.#: Are you an employer? Check the appropriate box; E Type of project(required): 1.❑ 1 am a employer with 4• ❑ I am a general contractor and T rf 6 �, construction employees (full and/or part.timt).* have hired the snb-contractors,; listed on the attached sheet 7. El Remodeling 2.❑ Y am a'sole proprietor or partner- These sub-contractors havoc � , ship and have no cmployces S. Demolition employees and have workers' working for me in any capacity. $ I 9, ❑Bui-ld.ing addition [No workers'.conzp.•imurance G°�' mst7orpoc, f` 10, •Electrical ma airs or additions- 5. [] We are a corporation and its � p 3. a ktomeowner doing all work officers have excrcised their 11_❑Pl=bing repairs or additions myself. [No workers' comp. right of exernption,per MGL 12.❑ Roof repairs in.s„rancc required]t c, 152, §1(4), and we have no employees. [No workers' 13.❑ Othex . comp, insurance required.? 'Any applicant that chaeks box#1 must also fill out the section below showing their workers'compensation policy information. t},.,Homcowncry who submit this a$tdavit indicating tbey arc doing all work and than hire outside contractors must subrr&a nm affidavit indicating such. "LAntSactnm that check thu box must attached an additional sbeot showing the name of the sub-contractors and sta.ic whether or not those cntidrs have ernployets. If the sub-contractors have cmploycs,they must pro-vidt their workers'comp.policy number. ram ors employer Ard is providing workers'compensation insurance for my employees. Below is the parity aril job sRe, ' information. Insurance Company Namc: Policy# or Self-ins, Lic. Expiration Date: Job Sitc Address: City/Statc/Zip: Attach a copy of the mrkers''compemsation policy declaration palV(showwg;the policy number and expiration date). Failure to sccuro coverago;as required under Section 25A of MGL c. 152 can lead to-the imposition of criminal penalties of a fine up to 51,500.00 and/or one-year 4risonm'ent, as well m civil penalti'es'in the form of a STOP WORK ORDER and d fine of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Tnvesti atioms of the bTA for insurance covers c verif catiOIL rdo hereby certify er the pains•and pen es bf perjury Ul&the informaffon provided abovesis rr e and correct Si afore: - Date, V — Pbonc #: Offxial use only. Do not write in this area, rb he completed by city or town official City or Town: Perminicense# Issuing Authority(circle one); 1. Board of Health 2, Building Department 3, City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6, Other Phone Contact Person; th Anformation and Instructions Massachusetts cneral Laws chapter 152 requires all employers to provid wor of,' c;Oanother undebroany o th0ir.tEoflhizecs; Pursuant to this hate an employee is defined as ...every person in the express or implic oral or written." hi association, corporation or other legal entity, or any two or more An employer is de cd as an individual,partners p, of the forcgoing.cng ce in a joint enterprise, and including the legal representatives of a g rroplo ecascd cs.lHowevcrhtbe rcceivez or trustee of individual,parbaership, association or other legal entity, employing uzp Y owner of a dwelling ho .e having not more than thrcc RjI aztments and who resides therein, or the occupant el the dwelling house of anoth who employs persons to do intcnance construction or repair work on such dwelling Douse or on the gzo aids or bvil g appurte neat thereto sha11 not because of such employment be deemed to be an employer." shall withhld the issuance ar MGL chapter 152, §25C(6) a o states that "every s to or local licasLug agency o renew2l. of a license or,permi to Operate a busin s or to construct buildings in the cornmOMYvealth for any applicant who has not produce •acceptable avid cc of compliance with the insurance coYerage required." Additionally,' MG ohaptcr 152, 5C(7) states ' iher the commmonwcalth nor any of its political subdivisions shall cater•iuto any contract for,the perfo ance of pub 'c work undl acceptable cvi.denec of comrpl P-nec Rzth the insurance zcquiremciats of this chapter have be presented o the contracting authority. Applicants Please fill out the workers' compensation Id Yit completely,by checking the boxes that;apply to your situation and, i# necessary,supply sub-contractoz(s)namc(s), CSS(Cs) and phone aumbcr(s) along with their ccrb_ficate(s) of insurance, Limited Liability Companics.(LLC r Limited Liability Partnerships (LL.P)with no cmpioyccs other than the members or partners, arc not rcquixcd to carry o ors' compensation insurance. If an LC or LLP does have employees, a po)c is required l3 e advised t thi affidavit may be submitted to the,Department of Industrial Accidents for confirmation of msuranec cover ge, o be sure to sign and date the affidavit. The affidavit should ested, not the Department of be returned to the city or town that the for..applica 'on fo permit or license is being requ Industrial Accidents. Should you have any stions rag ding the law or if you arc required to obtain a workers' l the Dcp fit at the nurn or listed below. Self-insured companies should cntc conopcnsation policy,please cal r their self-izrsurartGo license number on tho a rop ate line. CIty or Towp Officials .Plcasc be sure that the affidavit is comrplcte d printed legibly, c Departmcnt has provided a space at the bottom of tho affidavit for you to fill out irr the even; the Olficc of lnvestig bons bas to contact you regarding the applicant rence number. In addition, an applicant Please be sure to fill in the permiYliccnsc n er which will be use as a refe that roust submit�multiplc Pcrmit/license app, •cations in any given yc ,need only submit onp affidavit indicating current policy information(if accessary) and under ob Site Address" Cho app 'cant should write"all locations In (city or that leas becrt fficially stamped towza)."A cbpy of the affidavit or d mark 'd by the city or town may bo provided to the applicant as proof that a valid a$zdavit is on 'c for future permits or lice es. A new affidavit must be filled out each year.Where a home owner or cid7iCn is ob g a liccns e or p.ezznit not z ated fo any business or commercial venture (i_e, a_dog)icense or.permit to bum icaves etc,) said person is NOT require to complete this affidavit. .The Office of Investigations would h10 to thx, k you in advance for your coo eration and should you have any questions, plcasc do not hcsitato to give us a call no Department's address, telephone-and fax umber: Thb CbmmOnweal.th 0f�68Ssnh Pits D-,P tnaent of lad tl tdents Office, of RLYestipti Iks 600 Wa ,Mogen Stt=t Boston, MA 02111 Tel # 617-727-490.0 ext 406 or 1477-N-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.gov/dia y , Town of Barnstable ywP of IHE rp��� Regulatory Services Thomas F. Geiler, Director BAANSI'AHLE, .' • MASS. $ Building Division cb sG7P. �� Flo Tom Perry,Building Corrimissionet• . 200 Main Street, Hyannis., MA 02601 IA-Wjy.town.barustable.ma.us Fax: 508-790-6230- Oflice: 508-862-4038 HOA4EOWNER LICENSE EXEMPTION --- Please Print DATE: V JOB LOCATION: village ` number s Oct '� "IIOM✓OWNGR": home phone N : J work phone it naknc y CURRENT MAILING ADDRESS: cityltown state zip code ts or less gs of six U The current exemption for"home_— o_ e1S"was.extendedh re w o include p6ssIess a liven d`vrovided that the owner act and to allow homeowners to engage an individual for hire who does not possr supervisor. ¢ DEFINITION OF HOnIEOJIVNER' 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-fanuly dwelling, attached or detached structures accessory to such use and/or farm sb-uctures, A person who constructs more than one home in a itivo-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 4ezmit. (Section 1t09.1.1) 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 1.he/she understands then�o moo;B i with s be/P oceddu8resandent ntiru spection proced es and requirements and that he/she comply k re _me gn turc 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. ROMEOWNER'S EXEKPTION 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 Io9.),.1 Licensing of construction Supervisors);provided that if the homeowner engages a persons)for hire to do such work, that such Homcowna-shall act as supervisor," Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(sec Appendix Q, Rules &'Regulations for Licensing Construction Supervisors; of awareness often results in serious problems,particularly Section 2.15).This lack when the homeowner hires unliccnscd persons, In this case,our Board cannot proceed against the unlicensed person as it would ti�th e licensed supervisor. The homeowncracting as Supervisor is ultimatclyresponsible. part of the crntit a lication, To ensure that the homeowner is fully aware of hisAcr responsibilities,many communities require,asp p PP 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/ccrtification for use in your community. �opYH�ro � ` 'own of Barnstable ° Regulatory Services W-RNSrAULE, ` Thomas F. Geiler, Director p .wAn Building Division Tom Perry, Building Commissioner. 200 Main Street, Hyannis, MA 02601 www.town.barnst2ble.ma.us Office: 508-862-4038 Fax: 508-790-6230 P r.opert Owner Must oMPlete a Sign This Section If U ing .A Builder X , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work au orized this building permit application for: ddress of Job Signature of Owner Date Print Name If Property Owner is applying for permit please complete the Homeowziets License Exemption Potni on the reverse side. lu i Ll1 r -171 a , Ave wd. l e' � � a '•a 'V £YTv:.++y7 Te1:.k4:. ,FI:ICIil�:t'%��•�_••aw."^i�wi � sW,£�:aac9 �^F ',.-.v'R v.W.+.+♦ �'...1E.b<aXY 4 . !. .1 _ f� �,d"' $ MC7f C'xi 1ta IN SPEC: N i='LAW �+ cisTEAE.ci` A O SUR,v Yc f NAB JAMES L.. ROSEMARY,Y HAYL / 75 HAMMOND STREET" � FLOOR 2 vra c�.sr �?, MA 0]6tG�-t723 �I..{ CA'T'TC�;I i COLD f` ,GV F�, AD, FAx s564-752-889 = C NTERVILL� RMTOWSTGROURNET A. AivisiQtt, OfI#. 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ESA: "x r' 13 YfYH py;GPM REQUtPS"D fiY:RE.W tUG B,BY' �of1MErti Town of Barnstable BARNSTABLE. • Regulatory Services:--- 7 MASS. `�prEo .16, Building Division 200 Main Street,Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Inspection Correction Notice Type of Inspection CI P s- Location � G N d Cr(1:G yJ1c (f C Permit Number 1 Owner Builder One notice to.remain on job site, one notice on file in Building Department. The following items need correcting: IACA I-Ild iMlll- VC COJI-nUc�.s e,14-lrC STG'rwc'L/ r t r 1/J1,, Please call: 508-862-4038/for re-inspection. /1 /- Inspected by .�11C`�.e, Date 42 J0 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 2,147.034 Parcel, ,Applicatidn,# c2O Health Division Date Issued — li Conservation Division App cation Fee Planning,Dept! Perm'it Fee Date Definitivet Plan Approved by Planning Board CtI2_1101- (7 Historic =OKH Preservation Hyannis Project Street Address L4 C6 C qM(1\3 I Q_U Village U-: 1\ T*G-(Z-0 t L L Owner IZ05* e:'*' 14 A-'1 o-5 Address 14 Telephone 50% S3O - 736 0U.0 I Permit Request 4DC) oAi -no aK L!577AM7 6'_ /00/C e,14 Z tO 15 4-1 V,1 AJ12 ea,,4j ETC hi s PeAJ VP 1'r_J T6*1__tJ Squarep —proposed Total new feet: 1 st floor: existing roposeA-ZLIO 2nd floor: existing Zoning District Flood Plain Groundwater,Overlay Project Valuatio$ 5 ow Construction Type Lot Size Grandfathered: Ll Yes LJ No If yes, attach supporting documentation. Dwelling Type: Single Family .,,)k Two Family Ll Multi-Family (# units) Age of Existing Structure Historic House: LJ Yes Ll No On Old King's Highway: LJ Yes 0 No Basement Type: 0 Full 2(Crawl Ll Walkout Ll Other a . 0 Basement Finished Area (sq.ft. Basement Unfinished Ari'A(3q.ft) Number of Baths: Full: existing. new Half: existing _2L r,-.3 never Number of Bedrooms: 2 existing new Total Room Count (not including baths): existing new First Floor Room 0Wnt q I — Heat Type and Fuel: 9 Gas D Oil LJ Electric L3 Other %0 Central Air: LJ Yes '*No Fireplaces: Existing I New Existing wood/coal stove: LJ Yes 10 No Detached garage: J existing J new size—Pool: LJ existing LJ new size Barn: J existing Ll new size Attached garage: LJ existing L3 new size Shed: LJ existing L3 new size Other: Zoning Board of Appeals Authorization Ll Appeal # Recorded L3 Commercial Q Yes ;d No if yes, site plan review# Current Use 5'hriuc-7 Proposed Use a- 14AA APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Namek � Telephone Number -56:6 7, Z � '7 6 6 -7 Address Fb ZqC1 N A 0 mA License# Home Improvement Contractor# V Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO vow 14 SIGNATURE DATE } FOR OFFICIAL USE ONLY `► J APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION 4 3o)a9 la 06o9 FRAME St t c L�t f �l-J91 � CLg) � INSULATION bet o FIREPLACE :a ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL ' FINAL BUILDING ��7.illlo '4 DATE CLOSED OUT ASSOCIATION PLAN NO. f The Cotntnonwealth of Massachusetts Department of Industrial Accidents Office of Investigations* , 600 Washington Street Boston MA 0211, �. www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LefibI Name (Business/Organizadon/Individual): Address: o `goX 24(� I City/State/Zip: NA-Nt0c.Y—e_-1' AAA 025bq'',Phone:M (50b� 2Z8 -f-0CQ'4 Are youan employer? Chee he appropriate box: f�. Type of project(required): 1.[ I am a employer with 4. [] I am a general contractor and I * have hired the sub-contractors 6. ❑New construction employees (full and/or part-time). Remodelin 2.0 I am a soleproprietor or'parhler-' Iisted'on the'attached sheet. 7•. 0. g ship and have no employees These sub-contractors have S. •Q Demolition working for me in any capacity. employees and have workers' 9. �uilding addition [No workers'•comp.-insurance comp:insurance. required.] S. [],We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work tr officers have exercised their 11.0 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 13.❑ Other employees. [No workers' e" comp. insurance required.] *Any applicant.that checks box#1 must also fill out the section below showing thcir 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 thcir workers'comp.policy number. lam an employer that isproviding workers'compensation insurance for my employees. Below is the policy andjob site information. / �• Insurance Company Name: Al c/hm�C%Q� I� , Policy#or Self-ins. Lic.#:o' 00(QC( &P-_-go3 ExpirationDate�4/ogla®1 0` Job Site Addres,46 0 CW,-AeoiU.e I� 1�t City/State/Zip: Attach a copy of the workers' compensation policy declaration page (show%ng the policy number and expiration date� Failure fo secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of crirnuial penalties of a fine tip to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the',form of a STOP WORK ORDER and a nte. of up to$250.00 a day against the violator. Be advised that a copy of this statemerii-ma y be forwarded to the'Office of Investigations of the MA for insurance coverage verification. I do hereby certify under the pains and penalties ofperjury that the informationpro,videdd a bove is true and correct. Signature Date D S l 1 Phone#: Z25 - :71 (0Ul'�, Official use.only. Do not write in this area, to be completed by city or town offlciaL 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 ('.nntanf Pr.r.cnn: Phone#: I formationan d Inst�rndions Massachusetts General Law chapter 152 requires`all employers toproeidervice of anoth r ender any contractoflhirees. Pursuant to this statute, an em oyee is defined as every person m empress or implied, oral or writte " An employer is defined as"an indivi at,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint ente * ise,and including the legal representatives of a deceasedmplH er,or the tiv receiver or stee of an individual,partne 'p, association or other legal entity, employing employers- r the owner of a dwelling house having not more a three apartments and who resides therein, or the occupant of the dwelling bouse of another who employs perso to do maintenance, construction or repair work on such dwelling house o'r on the grounds or building appurtenant thereto 11 not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every st e or local licensing ag cy shall withhold the issuance or ' renewal of a license or permit to operate a business to construct buil ngs in the commonwealth for any applicant who has not produced-acceptable evidence co,mpliance.wiA the insurance coverage required." AdditionaIly,MGL chapter 152, §25C(7) states`Neither e commonw Ith nor any of its trance subdivisions shall enter into any contract for.the performance of public work to accep le evidence of co requirements of this chapter have been presented to the con tr cting thority. Applicants Please fill out the workers' compensation affidavit completely hecking the boxes that apply to your situation and, if necessary,supply sub-contiactor(s)name(s), addresses)and one umbers) along with their certificates)of insurance. Limited Liability Companies*(LLC) or Limited ability rtnerships(LLP)with no employees other than the members or partners, are not required to carry workers'.co pensation urance. If an LLC or LLP does have employees,a policy is required. Be advised that this affi vit may be su tted to the Department of Industrial Accidents for confirmation of insurance coverage. Als e sure to sign a date the affidavit. The affidavit should be returned to the city or town that the application for e permit or license is ping requested,not the Department of Industrial Accidents. Should you have any questions garding the law or if yo are required to obtain a workers' compensation policy,please call the Department at e nur4ber listed below. Se nsured companies should enter their self-insurance license number on the appropriate ' City or Town Officials Please be sure that the affidavit is complete'and tinted legibly. The Deparmrent has pr vided a space at the bottom of the affidavit for you to fill out in the event Office of Investigations has to contact y u regarding the applicant. Please be sure to fill in the perinit/license num er which will be used as a reference numb In addition, an applicant that must submit multiple permit/license appl' ations in any given year,need only submit b e affidavit indicating curreno= policy information(if necessary)and=unde-r' ob Site Address" the applicant should write"all locations in town);".A copy of the affidavit.that h officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is o taming a license or permit not related fo any business or commercial venture (i.e. a dog license or permit to burn leav s etc.)said person is NOT required to complete this affidavit The Office of Investigations would lik to,thank you in advance for your cooperation and should you have any questions, please do not hesitate t6 give us a cal The Department's address, telephone-and fax number: ` The, Commonwealth ofMassachusets , Deepar4nent of ladustrial Accidents Oface of lavestigadQns. 600 Washington Street Boston, MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 11-22-06 WWw.mass.gov/dia G ACORD,- CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 03/05/2009 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Cowan Insurance Agency,Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 359 Main Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Haverhill MA 01830 INSURERS AFFORDING COVERAGE NAIC# INSURED W McEachern General Contractor LLC INSURER A: Nautilus Insurance Company POB 2461 INSURER B: Insurance Company of Pennsylvania INSURER C: Safety Insurance Company Nantucket MA 02584 INSURER D: INSURER E: COVERAGES 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,-RESP_EC?. TO.`NHICH THIS CER-T+F+GATE-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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD'L POLICY EFFECTIVE POLICY EXPIRATION POLICY NUMBER Y1 DATE IMMIDDIYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE $1,000 000 A X COMMERCIAL GENERAL LIABILITY NC866298. 02/04/09 02/04/10 DAMAGE TO RENTED S(Ea occure $100,000 CLAIMS MADE FO OCCUR MED EXP An one person) $5,000 PERSONAL&ADV INJURY $1 OOO,OOO GENERAL AGGREGATE $2i000;O00 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 X POLICY PRO- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $1,000,000 C ANY AUTO 5021250 511/2009 5/1/2010 (Ea accident) , ALL OWNED AUTOS. BODILY INJURY $ X SCHEDULED AUTOS (Per person) X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY N AUTO ONLY-EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGG S _ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR El CLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ WORKERS COMPENSATION AND X WC STATU- OTH- B EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE WC006956363 02108/09 02/08/1 O E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? If yes,describe under NO E.L.DISEASE-EA EMPLOYEE $500,000 SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $506,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Attention Risk Management rGeneralntractor. ATE HOLDER CANCELLATION SHOULD ANY OF THEABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Town of Barnstable DATE THEREOF,THE ISSUING INSU 1.RER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN 230 South Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Hyannis,MA 02601 REPRESENTATIVES. AUTHORIZED REPRESENTATIVE 5(2001/08) ©ACORD CORPORATION 1988 IF RTGAGE INSPECTiON, PLAN Vol ECISTE-PE 1 LAND SURV YORS NAME JA ES L. & ROSEMA`R HAYED (. :75 HAMMOND STREET — FLOOR 2. WOOCESTER M.A 01610 -1725 LOCATION` 466 OLD CRAIG,AlL .... RbAb NONE 50s=75;2—BB$$ cz � RMT0mSTCROVPWET 09 A IJEYIS14Ft 61 H. S. dt. Group,Irt . SCAB - _, I3 3 ' — --- RI�EU ooexiaRE�lyt sul�ets,sty age— �, VWS WEP,E C�,TW RKWW MO�aau,� �+i�t� .117 EASE ARE SKOW MD'TKEK,ARt Ma afl crxKttr tlanr,T1{E Dust s t#'..�ud�NtNf kF'L'!luitAikTtl$--RC i?IItNMG sm6�GA! s 1Cf�# FtETRTY. .+{3 AYE w,Y nm ice, - "rx�ts€ s i v, swrs :�s;Rn�iutwt t c{r.'. ,: .1104r+K"D ARE&, SEE r UAP; t5l ASA91dt5HTt3A� " - _ «- C' �ai. Y ff4-.dAOT 4 "tt5 2, - s.7 _ �}YY,��-^-�.�.-,.••K�`� . 51+R47H LUCA3�1N-tYC fifE sSTRQ>rri $'�&t'J'SyW Ma ON IS 41MER ti n1+0 a{?yZ Veo a{9NC.W&'CEC4 DMRMINEV OY SME 000 I tzTUP€�6ttc€:van+wc� zNc�sut PtzTr c � r era Nt »AR6Y+RWtrPAtE. uN/t€ 0& li'NE altos REd3RiURENT:NTS 'QR!3 E71EkT FFRBkF 5rpt.�TliF�#T t - # S>tl{1NOEB G.L.Ti7TS t� Clis4' SRO. SEt Uts�. 'S b �#'".,r F'4�L Ja#133 CtR`A VERMA-'CxklY7tiSL>d1M- Tz, l TH� nog n csmrn; x ttwss�a - - �- : AHOJE.GERTI(1ChnQtiS MYaiH'nfF?-t;Ro}6-btAY' 1U �� .p - "OR&1.R't, t ?€; t5.ES£4'hTiLbgdS +PMf1T BE ii.€ffRMd4b€4. 7fTTr=WoRmi"P(RO+I'OE,p'T a e ATC.�tR6 T3iiKl=3t91n ASt ,' _ f m usm ARE+ t ;1 trtbtAtm vi arlAnm o,THE - r NN 90 a u� r HOUSE #-466 `3' r LOT 5A 7,.500 5,F.f � , 0 s tti V17Y5"nNG aTMICC..Ft R, VCON I:A„ JR.. ESQ. p :41{N HYi Cad RFQEf I$U tor.: R_W CRECXED RYt. i ,, �'fee-r�omar�zoou�eal� o�./�iooaelzueeCta Board of Building Regulations and Standards Construction Supervisor License License CS 55294 Ecpirat1on 5/5/2010 Tr# 23866 `Resh�etion 00_ WILLIAM F MCEACHERN PO BOX 2461 NANTUCKET.MA 02584 Commissioner Boar o ui 1n 1at�ons an taann �rsa One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement-Contractor Registration Registration: 146686 Type: Ltd Liability Corpor Expiration: 5/10/2011 Tr# 283160 W. MCEACHERN GENERAL CONTRACTOR. . -. WILLIAM MCEACHERN P.O. BOX 2461 NANTUCKET, MA 02584 Update Address and return card.Mark reason for change. Address Renewal Employment Lost Card DPS•CA1 0 40M-08/08-DBSLIFORMCA108212008 aoiea?'s!u1U1P� `45SZ0 t/W'1371Of11.NdN aan;eug!s;noq�jm p!leA)ON 3IWt,0 NNtI At,t/W Z/l 6 — N83HOV3M WdII1IM 011-d0.Lo 8J_N0O'1V113N30.NU3HOV30W M aodioO l MPS!l Pik :ad/ll 'elA[`uolsog 09l£SZ #al 160Z/0415 :uoijealdx3 $OIZO 9299V 4 :uol;e�;sleet, IO£t wg 0381d uo1anggsd auO spaspug4g pue suo!;elntau gulpl!nalo paeog Nolo�NOO 1N3MAOHM 3WO14 :01 u.an;aa punoj 31i *all' uo!;ea!dx1 aq;aao;aq us Soo nga gm irn s piloa ,quo asn lnplA!Pu!ao,!p!IeA uopuJIS03 ao asua3!� g �� � 'wo -67/29/2609 14:12 1s �9.654 3. WFA,GEN CONTRACT 81 Kz ' ownv -Barmstablie - e ulatory'Services 91 Tlom Perry,S,41]di*g Comn-&Aootr 24#!&Sein'Strc�t,�ypta�,l�A f126�2 fi3f Fax: 508-790.6230 `: :'. gletz Sign, section . Lf Rum C_ W Baer'off t}� ubj p hereby aurhorizm to;Wtonmy ira Al rka3zed bys b' s te s�xzat ppf aon fir, Not M=l x atft ' applying fir permit; a v p et to o xeowners lee,�se;F'emp6Dn am ors r side, EIS ERG'Y CONSERVATION APPLICATION FORM FOR ENERGY EFFICICIENCY FOR ONE; Al D TWO-FAMILY DETACHED RESIDENTIAL'CONSTRUCTION (780 CMR 61.00) Applicant Name: ��� C/� J �. L- LCC Site Address: print Town: Applicant Phone: 120' Z e& 76 7 . Applicant Signature: Date of Application: �'�aC✓ — NEW CONSTRUCTION: choose ONE of the following two'o tions 780 CMR TABLE 6107.1 PRESCRIPTIVE ENVELOPE COM)TONENT CRITERIA FOR NEW ONE- AND TWO-FAMILY BUILDINGS MAXIMUMMINIMUM Ceiling or Slab Option 1: Basement Q Fenestration exposed Wall- Floor Perimeter Wall AFUE HSPF SE. U-factor floors R Value R-Value R-Valua R-Value R-Value and Depth National Appiiancc•Encrgy 3 5 R-10, Conscryation Act(NAECA) R-3 8 R-19 R-19 R-10 4 ft. 1987 as amcndcd,minimums cattr as jipplicabIr Note: This form is not required if you choose either of the two versions of REScheck as listed below. Option 2: REScheck Version 4.1.2 or later variant software analysis must be completed 780 CMR 6107.3.2 REScheck--Web which can be accessed at http://www.(-,ntrgycodEs.gc)v/rescheck/ ADDZX' OIVS;OR AI,`f RA1'XOI�S.TO EXISTING BIAL*D; I IGS.O: R5 YEARS OZ,b* *puildiags under S years old must use option#1 or#2 in New Construction section above. Complete the following formula to determine the %o of glazing: (a) Gross Wall & Ceiling Area equals Formula: (100 x b- a) l 1 SF 100 x �O`�U� _ . % of glazing (b) Glazing area equals �il SF b a If glazing is<:40%.u.9e.the chart belpW. • . If gla±iDg is > 40 %' rocee,•d to"SMIWOM" section 780 CMR 'TABLE 6101.3 PRESCRIPTIVE ENVELOPE COMPONENT CRITERIA ADDITIONS TO EXISTING LOW-RISE RESIDENTIAL BUILDINGS M.AXM4UM MINM UM. Ceiling and Slab Perimeter Fenestration •Wall Floor Basement Wall R_Value U-factor Exposed floors R-Value R-value R-Value R-Value and Depth 39 R-3 7 a R-13 • R-19' R-10 R-10, 4 feet a R-30 ceiling insulation may used in place of R-37 if the insulation achieves the full R-value over the entire ceiling . . area(i.e:not compressed over exterior walls, and including any access openings). SUNROOM—An addition or alteration to an existing building/dwelling unit where the total 0 glazing area of said addition exceeds 40% of the combined gross wall and ceiling area.of the addition. Note: Owner to fill out Consurner Information.Form found in Appendix.120.P I I! a � a ea 5inpsonstron9-ne.H 10A OF QA 8 i e s list So tlL c>To A � 5 A� LA A-4- M A. J Cr ROL� C��r �er�; /lam o PEA Al Skai�/r-0� 7�r-r�oz� i * TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel. Application # Health'Division Date Issued w �o o Conservation Division Application Fee �(D Planning Dept. Permit Fee `1 Date Definitive Plan Approved by Planning Board ak /0/4/09 Historic - OKH Preservation/Hyannis Project Street Address A4l Village ��ilL TLZZ V/LG� Owner l� e S Address Telephone C> D? ST� Permit Request Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 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's Highway: ❑Yes )(No Basement Type: El Full ❑ Crawl ❑Walkout ❑ Other l Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) 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/coo 1 stove: Q Ye No ca Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ fisting ❑ qew size_ Attached garage: ❑existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# - -Current Use - - Proposed Use - APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name ATelephone Number Address w 2�2a///0 p 6z) License# 6I OR alloe) Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER I DATE OF INSPECTION: FOUNDATION FRAME :F INSULATION FIREPLACE ` ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL • GAS: ROUGH FINAL FINAL BUILDING a Z� 4 DATE.CLOSED OUT ASSOCIATION PLAN NO. 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 Le ibl Name (Business/Organization/Individual): _e2 5� JQ- Address: — � City/State/Zip: �'� Phone o Are you an employer?Check the appropriat 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 working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.1 [,squired.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.I�'I am a homeowner doing all work officers have exercised their 11.0 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 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. .t Insurance Company Name: Policy#or Self-ins. Lie. #: 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 copygof this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. it 1 do hereby certi nder the pains a d nalties of perjury that the information provided above is true and correct. Signature: Date: Phone M 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#: r. Information and Inst actions 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 rvice of another under any contract of hire, express or implied, oral or written." An employer is defined as"an ii1dividual,partnership, association, co oration or other legal entity,or any two or more of the foregoing engaged in a joint�enterprise, and including the lega epresentatives of a deceased employer, or the receiver or trustee of an individual, artnership, association or other egal entity,employing employees. However the owner of a dwelling house having noN ore than three apartments d who resides therein,or the occupant of the dwelling house of another who employs ersons to do maintenanc , constriction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not becaus of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that" ery state or loca icensing agency shall withhold the issuance or renewal of a license or permit to operate a b:siness or to co struct.buildings in the commonwealth for any applicant who has not produced acceptable a ence of co liance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7) states" ither the c mmonwealth nor any of its political subdivisions shall enter into any contract for the performance of publi work Lin 1 acceptable evidence of compliance with the insurance requirements of this chapter have been presented to th contr,cting authority." Applicants Please fill out the workers' compensation affidavit coNenby checking the boxes that apply to your situation and, if necessary, supply sub-contractors)name(s), address(e one number(s)along with their certificate(s)of insurance. Limited Liability Companies (LLC)or Limbi 'ty Partnerships(LLP) with no employees other than the members or partners, are not required to carry workersnsa 'on insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this aay b submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Alre to si and date the affidavit. The affidavit should be returned to the city or town that the application for tit or licen is being requested,not the Department of Industrial Accidents. Should you have any questions r the law or you are required to obtain a workers' compensation policy,please call the Department at the listed below. elf-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 print legibly. The Departmen\nn ovided a space at the bottom of the affidavit for you to fill out in the event the Off e of Investigations has to ou regarding the applicant. Please be sure to fill in the permit/license number w 'ch will be used as a referen r. In addition, an applicant that must submit multiple permit/license application in any given year,need onlit e affidavit indicating current policy information(if necessary) and under"Job Si Address"the applicant shoite"a locations in (city or town)."A copy of the affidavit that has been offici ly stamped or marked by ther town ay be provided to the applicant as proof that a valid affidavit is on file fo future permits or licenses. Affidavit ust be filled out each year. Where a home owner or citizen is obtaining license or permit not related business or ommercial venture (i.e. a dog license or permit to burn leaves etc.)sa' person is NOT required to ce this affidavThe Office of Investigations would like to thank u in advance for your cooperad should you ha e any questions, please do not hesitate to give us a call. The Department's address, telephone and fax nu her: The Co monwealth of Massachusetts Dep ment of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax # 617-727-7749 www.mass.gov/dia I ENERGY CONSERVATION APPLICATION FORM FOR ENERGY EFFICICIENC•Y FOR ONE,- AND TWO-r Y DETACI ED RESIDENTIAL CONSTRUCTION (780 CMR 61.00) Applicant Namc. S'� Site Address: 'print Town: Applicant Phone: Applicant Signature: D to of Application: S NEW CONSTRUCTIO choose ONE of the folloWin two'o tions 780 CMR TABLE 6107.1 PRESCRIPTIVE Er TYTLOPE CC1I�POI`dEr;T CRITERIA FOR NEW ONE- AND TWO-FAMILY BUILDINGS MAXIMUM MINIMUM Ceiling or Slab El Option 1: Fenestration exposed Wall Floor Basement perimeter Wall AFUE HSPF SEET U-factor floors R-Value R-Value R-Value R-Value R-Value and Depth National Appliancc•Encrgy R-10� Conservation Act(NAECA)of .35 R-3 8 R-19 R=19 R-10 4 ft . 1987 as amended,minimums or cater as a licablo Note: This form is not required if you choose either of the two versions ofREScheck as listed below. ❑ Option 2: REScheck Version 4.1.2 or later variant software analysis must be completed 780 CMR 6107.3.2 REScheck--Web which can be accessed at http•//www.ggqr codes.f7oy/rescb ckl :A-DDITIONS:OR-A - ERA` 1OiZS.TOEMTINGBULLDZNGS,.OV 125YEAI2SOLD* *)3uildings under S years old must use option#1 or 42 in New Construction section above. Complete the following formula to determine the %o of glazing: (a) Gross Wall & Ceiling Area equals Formula: (100 x b = a) SF 100 x - _ % of glazing (b) Glazing area equals SF b a If lazin �s<40%.use the chart below. If lazing is > 40 % rocee.'d to "SUNROOM" section 780 CMR TABLE 6101.3 PRESCRIPTIVE ENVELOPE COW ON-ENT CRITERIA ADDITIONS TO EXISTING LOW-RISE RESIDENTIAL BUILDINGS MAXIMUM MINIMUM Ceiling and Wall Floor Basement Wall Slab Perimeter Fenestration Exposed floors R-Value U-factor R-Value R-Value R-value R-Value and Depth .3� R-37 a R-13 R-19 R-10 R-10, 4 feet a R-30 ceiling insulation may be used in place of R-37 if the insulation achieves the full R-value over the entire ceiling area(i.e, not com ressed over exterior walls, and including any access openings), ' SUNROOM—An addition or alteration to an existing building/dwelling unit where the total. glazing area of said addition exceeds 40% of the combined gross wall and ceiling area of the. addition. Note: Owner to fill out Consurner Information Form found in A endix 120.P Town of Barnstable mop THE t o Regulatory Set-vices RA SrA13 Thomas F. Geiler,Director KAas. 1659. a,� Building Division rED htA't Tom Perry,Building Commissioner 200 Maiu•Sireet, Hyannis,MA 02601 .t www.town.barnstable.ma.us Office: 508-862-4038 Fax: S08-790-6230 +HOMMOWNER LICENSE EXEMPTION Please Print y DATE: JOB LOCATION: L 6 /n9-12 J/ number strpct - t village y - --`HOMEOWNER": Aso nam home phone# work.pbom# CURRENT MAILING ADDRESS: 2� G F� �- mil - �i2_ 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 hwneowners to engage an individual for hire who.,does not possess a license,provided that the owner acts as SuperyisOl. i, DEFINTI`ION OF HOMEOWNER Persons)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 forin 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. 4 t The Unsigned"homeowner"certifies that-he/she understands the Town of Barnstable Building Department ection procedures and requirements and that he/she will comply with said procedures and re ments. i atone of Homeowner rrf Approval of Building Official #l, f ; Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to coinply with the State Building Code Section 127.0 Construction Control. ` HOMEOWNER'S EXEMPTION The Code statts that: "Any homeowner performing work for which a building pc=t is required shall be exempt from the provisions of this section(Section 109.1.] -Licensing of construction Supervisors);provided that if the homcowna engages a person(s)for hire to do such world;that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they arc assurmng the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness oftcn 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 liccnscd ' Supervisor. The homeowner acting as Superyis"or 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 hdshe 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 fori-n1ccrtification for use in your community. Q:forrns:homccxcmpt YKEr, Town of Barnstable Regulatory Services q ' erg` Thomas F_ Geiler,Director fa, a Building Division Tom Perry, Building Commissioner 200 Main Street,Hyannis,MA 0 01 www.town_barnstable. Cus Office: 508-86 -4039 Fax: 508-790-6230 Property er Must Complete and. S gn This Section If Us in A Builder as Owner of the subject.property hereby authorize to act on my behalf, in all matters relative to work au d by this building permit application for. Address o ob) Signature of Owner Date Print Name if Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. 537a oFtK*E r Town of Barnstable *Permit# �, ~O Expires 6 monde front issue date Regulatory Services Fee STABLE. + Thomas F.Geiler,Director 01 8v ` " Building Division 3 20a�ft.' Tom Perry,CBO, Building Commissioner TO VV/V O�8AR 200 Main Street,Hyannis,MA 02601 - www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS'PERMIT APPLICATION. - RESIDENTIAL ONLY j "'/ Not Valid.without Red X-Press Imprint Map/parcel Number ,/ �/ ` p Property Address esidential Value of Wor (/ Do Minimum.fee of$25.00 for work under$6000.00 Owner's Name&Address H _ Z_)o Contractor's Name Telephone Number 3 Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I ole proprietor Ukl-am the Homeowner. ❑ 1 have Worker's Compensation Insurance Insurance Company Name d 4 Workman's Comp.Policy#. Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) e-roof(stripping old shingles).=All construction debris will.be taken to r ❑Re-roof(not stripping. Going over ` existing layers of roof) e-side #of doors ❑ Replacement Windows/doors/sliders:U-Value (maximum.44)#of windows " *Where required: Issuance of this permit does'not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. v ***Note: Property Owner must sign Property Owner Letter of Permission. Ailding y of the Home I provement Contractors License&Construction Supervisors License is ± ed. SIGNATURE: Q:\WpFILES\FORMrms\E)PRESS'doc Revised'090809 S�x The Commonwealth of Massach usetts Department of Industrial Accidents Office of Investigations I' 600 Washington Street Boston, MA 02111 �Y y� www.rnass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual): .S Address: City/State/Zip: O/ j% EZ— Phone #: J '7..5'7 40e?4�� Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. am a general contractor and I t 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. T❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in an capacity. employees and have workers' y9. ❑ 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.❑ Plumbing repairs or additions right of myself. [No workers exemption comp. g p per MGL < 12.�oof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.[ er 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. 1 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 f Investigations of the DIA for insurance coverage verification. I do hereby certi der the pains n penalties of perjury that the information provided abo a i2 s tr w and correct. Signature: Date: 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#: Town of Barnstable o Regulatory Services anarrsrwsLe, Thomas F.Geiler,Director Mass. 1639. ,�� Building Division PTEp►�{.�a Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTIO/N Please Print /a DATE: ,I ,/ JOB LOCATION: 0/(L ( t/1 4_ ! num a street village "HOMEOWNER": nam home phone# work phone# CURRENT MAILING ADDRESS:T city town t✓ ate 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. J 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 Ofcial 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) r 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 mini inspection pro ce es and requirements and that he/she will comply with said procedures and re ents . r e gnature 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 heJshe understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by that the homeowner certify p p p g several towns. You may care t amend and adopt such a forn-/certification for use in your community. Q:\WPFILES\FORM S\homeex empL DOC THE Tp�, Town of Barnstable Regulatory Services , NAB& � Thomas F. Geiler,Director f�� Building Division: Tom Perry,Building Co ssioner 200 Main Street,Hyannis, �02601 www.town.barnsta e.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property er Must Com ' ete an Sign This Section Us' A Builder as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work au orized by this cling permit application for. (Address of Job) Signature of Owner Date Print Name Pro e Owner is applying for ermit lease complete the If p p P P �Y Homeowners License Exemption Form on the reverse side. QTORMS:OWNERPERMISSION i The Commonwealth of Massachusetts Department of Industrial Accidents. Office of Investigations I' J 600 Washington Street c +� > Boston, MA 02111 'Ry www.mass.govldia Workers' Compensation Insurance Affidavit: Builder's/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Jose, — � / 0 Address: 0 omt—, U V d 's City/State/Zip:�c-qia_ml—b t A MA- 0zV,4APhone #: b--o 0 7(DO 1 qS Are you an employer? Check the appropriate box: Type of project(required): 4. I am a general contractor and I 1.[ 1 am a employer with � ❑ 6. ❑New construction employees (full and/or part-time).* ha Fe`hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. " employees and have workers' 9. ❑ Building addition [No workers' comp. insurance , comp. insurance.$ 5: ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] � 3.❑ I a homeowner doing all work f officers have exercised their I LE] Plumbing repairs or additions myself. [No workers' comp. ,' right of exemption per MGL 12.0 Roof repairs insurance required.]t f c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box 41 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.#: VW G 1900 I Z D 49*0 I 0 xpiration Date: 2-0`0 . U Job Site Address: ei '(�1 1 le City/State/Zip:bnfu aZlO3Z old 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 e-rtify un r flit pains and penalties of perjury that the information provided above is true and correct Si ature: Date: '� - 2 = Phone# Ov —7�p0 , `3 Official use only. Do not write in this area, to be completed by city or town officia•L City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical'Inspector S. 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. P qP P Pursuant to this statute an employee is defined as "...every ry person inthe service of another u nder any contract of hire, express or implied, oral or written." An employer is defined as"an in ' idual,partnership, association, corpora on or other legal entity, or any two or more of the foregoing engaged in a joint nterprise, and including the legal repr sentatives of a deceased employer, or the receiver or trustee of an individual, p rtnership, association or other legs entity, employing employees. However the owner of a dwelling house having not ore than three apartments and o resides therein, or the occupant of the dwelling house of another who employs ersons to do maintenance, co sttuction or repair work on such dwelling house or on the grounds or building appurtenant hereto shall not because o Lich employment be deemed to bean employer." MGL chapter 152, §25C(6)also states that" ery state or local lic rising agency shall withhold the issuance or renewal of a license or permit to operate a b siness or to const ct buildings in the commonwealth for any applicant who has not produced acceptable a 'deuce of compl' nce with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states" ither the co onwealth nor any of its political subdivisions shall enter into any contract for the performance of public ork until cceptable evidence of compliance with the insurance requirements of this chapter have been presented to th ontrac ng authority." Applicants Please fill out the workers' compensation affidavit compNeb y checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s), address(es) a number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limiteit Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' ctio insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidy be bmitted to the Department of lndustria] Accidents for confirmation of insurance coverage. Also to sign nd date the affidavit. The affidavit should be returned to the city or town that the application for the r licens is being requested,not the Department of Industrial Accidents. Should you have any questions regae law or i ou are required to obtain a workers' compensation policy,please call the Department at the nuted below. elf-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 1 ibly. The Departmen\ai ovided a space at the bottom of the affidavit for you to fill out in the event the Office Investigations has to you regarding the applicant. Please be sure to fill in the permit/license number which ill be used as a.refereber. In addition,an applicant that must submit multiple permit/license applications in y given year, need onit one affidavit indicating current policy information(if necessary)and under"Job Site Ad ess" the applicant shote"all locations in (city or town)."A copy of the affidavit that has been officially st ped or marked by the to n may be provided to the applicant as proof that a valid affidavit is on file for futur permits or licenses. Afida it must be filled out each year.Where a home owner or citizen is obtaining a licens or permit not related usine or commercial venture (i.e. a dog license or permit to burn leaves etc.)said perso is NOT required to c this of davit. The Office of Investigations would like to thank you in ad ance 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 Commonwealt of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE l Revised 4-24-07 Fax # 617-727-7749 www.mass.gov/dia I WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Industries of Massachusetts Mutual Insurance Company Burlington, Massachusetts (800)876-2765 NCCI NO 26158 POLICY NO. VWC 6001886012009 PRIOR NO. VWC 6001886012008 ITEM 1. The Insured Jose Francisco DeSouza Mailing Address: 102 Captain Noyes Road S Yarmouth MA 02664 (No. Street Town or City County ;" State Zip Code ® individual ❑ Partnership.❑ Corporation ❑ Other FEIN 01-3760950 Other workplaces not shown above: 2. The policy period is from 08/13/2009 to 08/13/2010 12:01 a.m."standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here; MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily.lnjury by Accident $ 10 0,0 0 0 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States Insurance:Coverage Replaced By Endorsement WC 20 03 06A g D. This policy includes these endorsements and schedules: SEE SCHEDULE` - 4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Code Estimated Per$100 Estimated Total Annual of Annual No. Remuneration Remuneration Premium INTRA '251329 SEE EXT NSION OF INFOR ATION PAGE Minimum premium$ 500.00 Total Estimated Annual Premium $ 500.00 As indicated,interim adjustments of premium shall be made: Deposit Premium $ 512.00 ® Annually ❑ Semi Annually ❑ Quarterly ❑ Monthly MA Assessment Chg. $287.00 x 7.2000% $12.00* This policy,including all endorsements,is hereby countersigned by - 07/2012009 Authorized Signature Date GOV! GOY KIND PLACING CLAIM NAME SAFETY STATE CLASSI AUDIT I OFFICE OFFICE CHECK IGROUP Amherst Insurance&Real MA 5474 12 1604 Estate WC 00 00 01 A(11 88) PO Box 48 F Amherst,MA 01004 . Includes copyrighted material of the National Council on Compensation Insurance, a used with its permission. P A.I.M. Mutual 1989 _ . .,.. . 2009 INSURANCE COMPANIES 20 Years of Excellence in Service r J )- 3 r Jr ! t E Ell E p, ® icy CT zx <— ellDAM ;`< i IN v ai ��C . �� - i E ' i a w., i r i i , n s z F a • 3 r - t a •'� . .. . . - f ( , f , /PF 15 v . -- -- U �:l ,,,�, c ,,n��Gt Lq '— o CV.- _ r t i