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HomeMy WebLinkAbout0567 OLD CRAIGVILLE ROAD le 9 a ` a • d� ��- •� ,� yal !�`A n� � ���� .•� �h?rai{-t'��A�r�id�.s.-�it'yy f �..�rin� �'A•-',, 'a,�SIZ sd�- - 1. 4• .• , ,: ,>,,•' . e�� iu.• qa ` c.c>", yid fis .`�:a" �l-t;. 4'� a•.r! � r„ _ v r � , - n , ,r r A ro • :� � a :::. y ..,., y .... .. - s d4 Z � � 6 V* , h' e l .+n .}, /art Application num .....1.. 1.0 Q..,/... • Date Issued ........ ........................ MAM "• AL3AiST�ABL Building Inspectors Initials 4� A Map/Parcel.. . �......................... ' 'OWN OF BARNSTABLE EXPEDITED PERMITAPPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION r Address of Project: Ur� l� �rct v. c [ (-e' A,A t- NUMBER ST ET VILLAGE v Owner's Name: M a._1J-H F_114en AA i )(e_c °Phone Number S6 8' 7-7 2,2-q v/Email Address: b C_6 0LI�e` C1JQ- n etx on'1Ce11 Phone Number.3 4 6 � 0 Z Project cost $ �<oa ` j Check one Residential � Commercial -OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR I/ Owner Signature: LAA" [ 1 UYI L C Date: TYPE OF WORK fA Siding ❑ Windows (no header change)# Q Insulation/Weatherization 0 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 CONTRACTOR'S INFORMATION ti Contractor's name ®W� �7 Home Improvement Contractors Registration(if applicable) # 0��' � (attach copy) Construction Supervisor's License# S� (attach copy) Email of Contractor w�iloa� R\��C`' Phone number. '�0 3Yc9 ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN ` A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE PERMIT CAN BE ISSUED. APPLICATION NUMBER ...............................................r *For Tents Only* 4 Date Tent (s) will be erected Removed on number of tents total Does the tent have sides? Yes No (If yes please attach floor pl with exits marked) D�ensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Check one: this event is a: for profit non-profit event Check one: ood served Yes No Flame Spread heet of each tent must be attached. Provide a site Ian with the location(s) of each tent • . i If food is being se ed at your event please obtain a Health epartment approval between the hours . of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial eve is may require Fire Department approval, *\OOD/COAL/PELLE STOVES Manufacturer# .aJbck Model/I.D. Fuel Type r Offsets from combustibles:front left side right side HOMEOWNER' ICENSE EXEMPTION Homeowner's Name: f Telephone Number _ f Cell'or Work number I.understand my responsi ities under the rules and re lations for Licensed Construction Supervisor in accordanc with 780 CMR the Massachuse s State Building Code. I understand the construction inspec on procedures, specific inspection_ and documentation required by 780 CMR and the Town o Barnstable. Signature Date -PPLICAT9S SIGNATURE Signature Date 1,1113 All erM. , applications are subject to a building official's approval prior to issuance. a l The Commonwealth of Massachusetts Department of Industrial Accidents - Office of Investigations 606 Washington Street Boston,'MA 02111 ~V.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): t C Address: � City/State/Zip: �,ceZ�`ee��11nn A do1G�Z Phone#: O �� Are you an employer?Check the appropriate box: , Type of project(required): I.❑ lam 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. EJ Demolition working for in an capacity. employees and have workers' g Y P ty. t . 9. ❑Building addition [No workers' comp.insurance comp. 'insurance. required.] 5. We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work . officers have exercised their 11.Q Plumbing repairs or additions myself. [No workers'comp. right:of exemption per MGL ' 12.0 Roof repairs insurance required.]t c:152, §1(4),and we have no employees. [No workers' 13.❑ Other 1 G comp:insurance required.] *Any applicant that checks box#1 must also fill out the section;below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. , Insurance Company Name: Policy#or Self-ins.Lic.#: - Expiration Date: Job Site Address: �`t 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 a 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 u er a pains andpe4aldes of perjury that the information provided abov is true and correct © �3 l Signature: r �� Date: C3 Phone#: �r-�S 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. t 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, rporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the le 1 representatives of a deceased employer, or the receiver or trustee of an individual,partnership,association or o legal entity,employing employees. However the owner of a dwelling house having not more than three apartm d who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenanc construction or repair work on such dwelling house or on the grounds or building appurten\states o shall not because of such employment be deemed to be an employer." MGL chapter,152, §25C(6)also states ry state or local li ensing agency shall withhold the issuance or renewal of a license or permit to opesiness r to const uit buildings in the commonwealth for any applicant who has not produced accvidence f compli nce with the insurance coverage required." Additionally,MGL chapter 152, §25Ceither a co onwealth nor any of its political subdivisions shall enter into any contract for the performb 'c work til a eptable evidence of compliance with the insurance requirements of this chapter have beend to a con ctin authority." Applicants Please fill out the workers' compensation affidavit comple y,b checking the boxes that apply tp your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and a umbers)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liab 'ty erships(LLP)with no employees other than the members or partners,are not required to carry workers' compen 'on' surance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit in y e s mitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sur to d date the affidavit. The affidavit should be returned to the city or town that the application for the permi or lic a being requested,not the Department of Industrial Accidents. Should you have any questions regarding a law if u are required to obtain a workers' compensation policy,please call the Department at the number 'sted belo f-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 p vided a space at the bottom of the affidavit for you to fill out in the event the Office of Inve tigations has to contact y . regarding the applicant. Please be sure to fill in the permit/license number which will be ed as a reference number. In addition,an applicant that must submit multiple permit/license applications in any giv year,need only submit one .ffidavit indicating current policy information(if necessary)and under"Job Site Address" e applicant should write"all 1 ations'in (city or town)."A copy of the affidavit that has been officially stamped marked by the city or town in be provided to the applicant as proof that a valid affidavit is on file for future permi or licenses. A new affidavit m be filled out each year.Where a home owner or citizen is obtaining a license or pe it not related to any business or co ercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NO required to complete this affidavit. The Office of Investigations would like to thank you in advance fo your cooperation and should you have y questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: ` The Commonwealth of ssaGhusetts Department of Industrial cidents i Office of Investigatio 600 Washington.Street Boston,MA 02111 Tel.#617-727-4900 ext 446 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www,mass.govCdia t Commonwealth of Massachusetts ® Division of Professional Licensure Board of Building Regulations and Standards <' a Const`, tCfi►�ltly�iSpgrvisor fj CS-066582 .5' 1 ires: 03/14/2021. �rl i a 1K n THOMAS C WHITE, 415A MAIN S7EET 3 i CENTERVILLE NfAL026ki,, S�� Commissioner vy Registration valid tor.individ al use only i �� byre the.expiration date If`found'return t-e rtOtfrce of Cimsumer,Wfa�cs a+a=Busi_r5ess Fie jutatlbn k 10 Park Plaza-Suite 5170 Boston,iNA 0211 :IUNot�rAPO Without signature r rr; w.�G . T j '. Commonwealth of Massachusetts ® Division of Professional Licensure Board of Building Regulations and Standards Constr4-11`16 I§b rvisor CS-066582 f sue: Tres: 03/14/2021 THOMAS C VAITE, 416A MAIN S*iT, CENTERVILLE �c,/tiS:T_iL�� Commissioner sLai zWT ce on'n me% ifairsC& ua Aegufa NTtion HOME lMPROVEME CONTRACTOR , ! ,tY-PE PLC — 1'1.i21/2019 .ro. T•HOMAS C KER LLC. t;MASC Wt�1 � 41R5A:MAIN ST. F � CENTERVILLE,MA '} Unders iy. r ' �IAYANW§ 49 061 � a Town of Barnstable 'Terit# add Regulatory Services Sd8 Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,.Hyannis,MA 02601 www.town.bamstable.ma us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X--Press Imprint Map/parcel Number Property Address VResidential Value'of Work Minimum fee of 535.00 for work under S6000.00 Owner's Name&Address /�iG', '�'/zz"'J l_J 224 1 62 . Contractor's Name %�� ��,/� Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) OWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name W 0 ttartan 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 ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) Re-side ff of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)r#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is ' re red. SIGNATURE: f/ QIW RLEWORMSUilding perrnit foanslEXPRESS.doc R�sea as�all . g" ��I issachusctts - Department of Public Safct, Baard of Building R((,,u:lations:and Standard:~ Construction Supervisor License License: Cs 63537 DAVID R COX: PO BOX 401 S YARMOUTH, MA 02664 Expiration: 10/15/2013 (')nuuissiuner Tr#: 4314 ............ _�_ __ ._.._ ..._ — —___ .... _, _ _- -- _-- _ Office of Consumer Affairs&B siness Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date: If found return to: Registration -100497 Type: Office of Consumer Affairs and Business Regulation Expiration 3/252014 Private Corporatio 10 Park Plaza—Suite 5170 ^4 = Boston,MA 02116 DA D COX, David Cox 19 LAVENDER LN W.YARMOUTH,MA 02673 V z ' Undersecretary Not valid without signatur _ DA_ VID-2 OP 10: KG CERTIFICATE OF oAT11rrrrl LIABILITY INSURANCE 06 � 129191,1 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGWTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT APFIR AATIVEL,Y OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUlNa INSURER($), AUTHORIZED REPRESZNTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER IMPORTANT: If the Ctrtifeeate holder is an ADDITIONAL INSURED,the pollcy(les)must be endorsed. N SUBROGATION IS WAIVED,subject to the ORDs and if the Ions of the poder t:erlEtln policies may require an endorsement. A statement on this certificate does not confer rights to the cerUHeltte holder In item of such a arsetne s. PRoouR 508.771-1632 IE thwood Ins.ASerlaf►,Inc. 508-393-2965 Akin Street suite 9 • .--_�.. nnls,MA 001 INgURER A:Travelers insurance Com_pa ___ M1/111A .. 1►Id Cox,011G•�� w^—ry INSURER a: P.O. Box401 INSURYRc: -- ..---- S Yarmouth,MA 02664 I I COV TIFI TB N R: REVISION NUMBER: 1'H15► TO C!: !FY THAT TH8 pOLiClt18 OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED Asova FOR THE POuCY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER OOCUMZN WITH RESPECT TO WHICi!THIS INDICATED. MAY SE 188UE0 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. _., LIDETS TYPE CF IN5U ANCE LN:Y R CON OSNLRAL LULBI4ITY EACH OCCURRENCE S � 1_000� A poNMeRCIaL aEMeRAL LIAE0.I?Y 1481 M796 O3i14J11 03114112 P s� 300,000 J CLAW&M101 OCCUR MED 6XP( one perwn)y { _ 5,00 X r3Uflnesf CWnots _�_ ,PeRsowaL a Aov INJURY_ s __ 1`000,00 — OENERALAGGRRQATH».. § 2,000,00 OEN L.AOGREa�TE LIMIT APPLISS'pER; ..� PROOUCTS-COMPIOP AGO 3 _. -• __,?+000,0 SV _ POLICY P C BINGLF LIMIT AUTOMOBILE LIABLITY ow �_._._... _ ._. BODILY INJURY(Per piston) i AUTO ANY A _--..__.... L WYAUTOp SCMEDUL80 BODILYINJURY(ParaOGanIl 4^____._. 00 kON•OWNED R s HIREO AUTOS AUTOS _ ._..__......_ S....... ... UMBRSLLA WLB OCCUR 4 EACH OCCURRENCE _ 3 {XO6bSLNLB ._ - _1 CLAIMS-MADE wCEO oRllslrs COMPSNSATIONN , X vvG LI�TM7S ...... ER...._..,_..__._.._ AND lMPLOYlRs'LLM14 Y v l N 100 00 I N I A KUB91 OX742211 I 07115111 07115M2 p.l EACKi►CCIDENr_� s _. + A ANv PRoraR>:*avPARrrrER,execuTn+: . M"A 8%CL1JOKI? S.L.DISEASE•EA SMPLOY_ i ..,. 100,000 d 1 yPpK I B.L.DIMSE•POLICY UW S WON PAPOESCRPTION OF OPERATION6I LoCATiONs I VBl1 MZB (Aft-ACORD 101,AddWo"Remarks Scmdule,E more space is reoubed) C§-RTIFI2ATEN R CANCELLAT12N TOWNSAR SHOULD ANY of THE Asove DescRIeED aoucles BE CANCELLED seFORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN Town of Sometatfle ACCORDANCE WITH THE POLICY PROVISIONS. 230 Main Street Hyannis,MA 02601 AUTNORILED REPRESENTATIVE O J OSS-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010100) The ACORD name and logo are registered marks of ACORD f - Dqmr&nmt oflk&uoidAcddm.& OfInvedisadons 600 wtL19wagion S&Mt Boston,JU 02111 Mtn.SO%1&a Workers'compensation Immra$ce Affidavit Bmilders! sIP)ambters ADyNcaat Iafnrmaiion Please ant LM''bb Name I--, C� efay. �. Address: /,�l.,Pll�1 J, if , Zx c An an amployal Cbeck the appropriate boa: Type ct of ro e I. I am a employer v 4. I s a Smui l centcact or and I 6. Conmuction emp�oyee9 PA aadtcrpast-trme).* have hked the tears Q 2.❑ I an a acie pvpdetor or partnea Haut on the at ached shy 7. ling ship and have no employees Thew have S. Q DemoRtien wadcing Sor me in any capacity. employees and have wadws 9 a s F Brag addition 5. [No ararlcers'ooCOOP.insurance We a 10. repairs or additions -� ❑ We an oon and its ❑ 1 3.❑ I am a ha®wmw doing an welt ova have emmiu d dtair 1 d.Q Phbing repairs or additiow MOO myself[No wa&era comp. of � love no12.Q Roof repaim iumnance l t 1(4), f k employees.[Ko wodmm' 13-�Other comb.issuance I 'Atgy apptbcaDd dyat c6a�s Gas A►1 mast oleo 531 am tbs sact®a tattoer sbavi�gttaeataatiteets'ootape�atiaapottcy 8aeoaowwra alto stdtme Nds atiBdavir fo glhRy sta datog aTt aoodc and thin 4ite aats�e caot�tocs amst mftk a mwr aMdavit indicating inch tceuaactors mat cha&ittit boa:mast attacbee an addil—short Qaw&%tbo a of tt a nab em Wcmcc and auto whwd r cram Own ambits imve emegryaas. if the srtbtoonactsrs mwt tt eea,may Borst psnvida tts3r,tadtao comp.pcHcy autmbat: lam as euriew due faprrovfaliieg ww*ors I Conwensadoa insa ancs fer tray emypdapsar. Bedew is de poIL7 and fob alto . Insurance cry Nat:re: ���',t Policq d as Self-law.Lit.#: Z/.&Q a0p, Ftioa I?at+e: 1 Jab Site Address: 11 Citystatelep: Attach a copy of&a workers'eomptmsat km policy deelarz&u PW(shawing the PO&Y aottmber and espfrat6a date). Fubm to wcvre coverage as retluimd under Section 2SA of MM a 1.52 cos lead to the of ctimi W penalties of n fine up to$1,500.00 and/or one-year iwpaisooatt 4 as weR as civil pendties in the farm of a STOP WORX ORDER and a one of np to$250.00 a dap agaioat dhe violator. Be advised that a copy of dais statemeaot may be fiwwarded to the Office of Iavesagadoos of the DIA for kownwe coverage verifimU a. T do havby earl& dkepd as and 4fP0dJ"teat dle iqftnuasomprormw above Pa bats and eorrecat Date- j Pbuane#: Q,,L-hd a m only. Do not writ in tuts arra,sv be avmpleted'by city or&wwn qF dd I City or Town: Penuitlldeeaee fi laming Audwity(circle one): i.Board of Health 2.Bum,#Department 3.City/rowu Clwk 4.Esetnrlcal Inspeetcr S.Phaosbi ng Spector 6.Odwr f..aataet Person: Pbone#: 6 � 1 of� * Bnxrrsrest.E. • MASS. Town of Barnstable: 9 i639. `fig' Regulatory Services Thomas F.Geiler,Director Building:Division Thomas Perry,CBO Building Commissioner 200t Mai n Street, Hyannis,MA 02601 ; www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A�Builder I /V G as.O Ow ner of the subj ect property hereby authorize�J� `j%1' &7X Ato act.on my behalf, in all matters relative to work authorized by this building permit application for: (Address"of Job) y� f4 ) 2(e 1 Signa e of Uwrier Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. Q:\WPHLESTORMS\building permit forms\EXPRESS.doC Revised 051811 OPINE) 'Town of Barnstable Regulatory Services anxwsrnst.E. ' Thomas F.Geiler,Director 059. y Mass. $, �prra`0 Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 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 extende to include owner-• cu ied dwellings of six units or less and to allow homeowners to engage an individual for hire who does t possess/FHOOWNER e,provided that the owner acts as supervisor. DEF ON O Person(s)who owns a parcel of land on which he/she resid or inteside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory t such or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeo r. Smeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be res ons leuch work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for com i e with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she unders ds the To of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply ith said proc ores and requirements. Signature of Homeowner Approval of Building Official i Note: Three-family dwellings containin 5,000 cubic feet or larger be required to comply with the State Building Code Section 127.0 Construction Control. ' HOMEOWNER'S EXEMPTION The Code states that: "Any homeo er performing work for which a uilding permit is required shall be exempt from the provisions of this section(Section 1 9.1.1-Licensing of construction S ervisors); provided that if the homeowner engages a person(s)for hire to do such wor that such Homeowner shall act as's ervisor." Many homeowners who use this a mption are unaware that they are ass u ing the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for icensing Construction Supervisors,Sect n 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:\-gVTFILES\FORMS\building permit forms\EXPRESS.doc Revised 051811 �OFIKE r ti Town of Barnstable *Permit# �)() Q t7 Expires 6 �i'fi ✓ 'ssr a date Regulatory Services Fee • BARNSTABLE, v MASS. $ Thomas F. Geiler,Director i639• �� pTFD MAy�' Building Division Tom Perry, CBO, Building Commissioner 200 Main Street; Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax:.508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number t Property Address 'Residential Value of Work ��� Minimum fee of$25.00 for,work under$6000.00 Owner's Name&Address_,�'j',(�, 'e z3 z2aZ2 ���/L�Lz Telephone Number Contractor's Name G��i �,rrok Tele P Home Improvement Contractor License#(if applicable) /jJ/3�fx Construction Supervisor's License#(if applicable) L � ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor - RESSPERMIT' ❑ I am the Homeowner ❑ .I have Worker's Compensation Insurance MAY 14 2o_10 s P Insurance Company Name - 'y& ��� TOWN Or BARNST.ABLE Workman's Comp.Policy.# llxe Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check.box) t2/Re-roof(stripping old shingles)'A11 construction'debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders. U-Value (maximum .44)#of windows a"• *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. A copy of the Home Improvement Contractors License'& Construction Supervisors License is reqjWed, SIGNATURE: :/ Q:\WPFILES\FORMS\building permit forms\EXPRESS.doC Ro,,;�o,t nonQno ` +( The Commonwealth of Massachusetts Department of Industrial Accidents ! Office of Investigations 600 TVashington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Ledbly Name (Business/Organization/Iadividual): J�/ y/� --- Address: /?� - - City/State/Zip:_ 4 ' . 1 Phone i 1 a you an employer? Check the appropriate box: Type of project(required): l r21 am a employer with _ 4 ❑ 1 am a general contractor and I ❑ have hired ihP sub-contractors &. New construction employees(full and/or part-time),* 7. Remodeling 2,❑ 1 am a sole proprietor or partner- listed on the attached sheet. ❑ g 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.t lU.❑Electrical repairs or additions required,] 5. We are a corporation and its ❑ � 3.❑ 1 am a homeowner doing all work officers have exercised their I L[]Plumbing repairs or additions right of exemption per MGL oof re _ I. myself, [No-workers_.comp,. .._. _ ... ._ . . .....,_. 12.�L pairs [ insurance required.]t c. 152,§I{4),and we have no �- [ 13.❑ Other employees. [No workers' 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 cheek 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 anal job site information. Insurance Company Name:_ ,AQ..i'1/J �� �, �� Policy#or Self-ins.Lic. #: � l(�,(! l/' Expiration Date:__%14 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 e STOP WORK ORDER and a fin-, of up to$250.00 a day against the violator. Be advised that e copy of this staternent may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. l do hereby certify at er the pains and penalties f perjury that the information provided above is true and correct. Si nature: Date: / Phone# fv Official sese only. Do not write in this area, to be completed by city or town official, City or Town: Permit/License# Issuing Authority.(eircle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4.]Electrical Inspector 5. Plumbing Inspector b. Other Contact Person:__ Phone oA 1D RIP C��,` i Q.O. Box 401 c MA,02664 So. , Yarmouth, CS#063537 j (508) 775-3469 ---� HIRC#100497 p✓HONE SATE �(� � -7 — 7 I _� PROPOSAL SU0miTTEO TO I: TRf.E 6 O 40 - JUB :_p�ATiQN ti a i STATE ANQ 1+P DOGE /] I Joe PHONE pATIF OF PLANS — I:. aaCH+TEC, Vie heresy Suorn"t spec+f;ca+cos , A� y � - . , W.i..r�P-.:'-/s/-�G++A�� {"��.• �� _" N s �,`S�'.:..n,c3�i y a,.,_, ^,� �(f l 1� �SI � M•r_ ik III i r 77, r . r n, Y i! ..if/� C.+/vl..a• - . /Tt 1 _1p_�eL �X —�I ��..:.. ..-•-.. r ._..n.+ w..... ..: y A�: a.. 4 � n 4, .. .. a '^ : a ..-. .• *x Jl ddAh, 7 t •` a ...,.....�� "n-herehy:ao furnlsn material-and..!aCor. ,.c�rnplete In acCoruanct• with atone specifications, for the $�-pc`00 . fJ. a doiler5�$ d, I� ey^nenl lobe Made i sue. '.. c j 3 Y r 010, An ate a+-s,4usrenreed tq ew a spe ,fisd All warty .o be camateteo to p workma�Irke gvinCnte� ` t (� menrei atturo ng to sta^afard pfa�t� to::Any tiRerai,c.n or.deprsUon.Irom..anove speuf�ca• Hors nvoiwnp wire�osti N°u be r attired n+y,upoi wr+tt rirorders ana will become x d� ,'iri s ctiar�e over�an0 eho+eanc'e+tan-ata-A?+agreemalis co.t!pge,t von of r.es at ioenta T1++3 proposal may be t I'V7. del;" DQyond`'c`Jr Control z6Dwner,(o'gAr;'y !tee torndCn ana btne� nKe.sary (nsu(ente 1'- Our wce•ers are.,':y covered WY Workmen's,CoMpansation InEtiiarce "� tis «Nltrorawit by Lisip'�Ot'a`a� eptBC w(h'! tlaYs s t 3`I �.,Thp above pr.) es Oec,f tattion5 a rs - fI Slgna ----------^==— and Condit ons 8r ',att9fBtto y arid-are hereby accepted "rYou:arc et thor zed r, .c , T , .}, , to'do the work as spe rrad POyment w h be metlr as outl+ned abovE A P tance t� Date n: cc a . is frOrn.'r'etr:y Geddis FdlX1014O:thW0Od r+Surance age L OT t Va:C 4'4wlU U+r'.Ur rlvt rayv.a ,L CERTIFICATE OF LIABILITY INSURANCE OP ID KG s( "VID-2 04 20 10 CERTIFICATE 16-ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Northwood Ins. AQanCy. Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 540 Maim Street, Suite 9 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Hyannis Mal 02601 Phone! 508-1'71-1632 rax:508-393-2955 INSURERS AFFORDING COVERAGE �NA1C# IPJ_IJRER A '.Tzev�iesa Intutaeta ce>tQan• paviSd Inc. ax'4 S Yarmouth MA, 02664 � N77REP 7., - TIS+JRER= - COVERAGE6 TI-E F'Ct.ICJc'S 6F I iSWi.MJCF.LiRrED 3F.Lir1"J HONE SFE-d 1SSU2D'O T-.F. itAMFD ASOV�'OR TIE PJL',:Y PER90D iND!CA,TED fiCTI'!TI•R;TAN 4I4C- rr REQLIRU.4h.T ' NPC OF COr1pl';(av OF A J'i CDir?L�d_T Gt:v? t4 U-':U Ev f'Pr!?H RESPE/_'`'. :'N :H-+'.:><ERT;Fir:r r,A. EE SSVEC'OP i :�.v'r FEFT�r•:.THE iYul%R,-Ne-E EIFFC'RCED BY "'E?C:IC FT DESCR,MD-JE,Ety R"iti:31ECT-U ALL'liE kP.7,c�::!:I:Va a*.o�ONr4^Ja.';.F i PC•a Cf: ?:•REGf•TE Wwa1".4•K>'F T!!AY hWNE SEE F:Z%CE-E:r PriaD CLAIN! .. L-R d9RQ YFE OF IN INCE POLI?Y tJUMBEi2 •10ATE(b1h 20A'1'Y ) -0,4TE 1Af iODrYY1`Y: I L!MMS j GENERALLIAsurv, EACH, CURRDrZ �S1000000 A cor,su=_Ftvti eEtti 1418IL17Y t PPE'MiSES:Ea ,<,� I _3000_00 �AIMSI•.'1?.^E :X r,; I IIAEOSrP(on��nds;arsc•I '-5000 ?C BUSineSs Owners 16801481ri796 03I14j10 03/14/11 �F_ rrwleL�sv :+q 91000000 I CENEFAL:,suPE,. ;2000000 - �VEr'i.AC+:fiE'`•AT,'.L%MITfr'P-!��PER. ! - ':� !'rFv[L• WIF/,`?: _ 't2000000 T ..� i r PRO• r—I ( i AUTOMOBILE UA&UTY j I C.-+46111EG B!W--LE LWIn I ANY a,i"O . ' ;ALL QW4EM ALTOS _!IfIR.DPl1 0: ! BODIL INX:ZY I I I N;^:•bW'�EC:+U1'CS � ( (pal avid?mi PP tFERTi CAIVAGc I gFRA.OE LIAOL �AJr0ONLY•EAAC,:IDE�T r t i + r'. EA NYAi.r4, (I' EXCESS i UMBRELLA LIABILITY I ! EAI H'Ct RAN �•_-,� -!Jk LKIMS MADE DEC+I,C`"iBLc- I I I s , I . RETEhtr 1 A/!D ENPLCYEiiS'LIA8lL!TY Y i N RIVY FRIIi F!EIOF?FPF+:NER,r_xE'U-,,E 6KU391OX74220.9 07/15/09 07/15/10. E L.s a^ _,_nT 1 s 100000 A OE=ICER/nlEh46ER c•K� E'1? l (Mmdaoryr In NH} E L.DI;`EASE•EA E\fr..':'EE r 5 00 0 00 ryes desonLounds De*'Y - ,. E L p,�:E•P01-f':i LIfiIIT ¢500000 OTHER Dj&ClRf I `IP .J OR OPE. r L4CA _ i VEHICLES i INCLQSIONt ADDED BY ENDORS&WENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD AM OF THE AEOVE DESCRIBED POLICIES BE C44CI LLED BBFORA"EXPIRATIOti TO BAR DATE THEREOF,THE I9;UHdO INSURER PALL ENDEAVOR TO M41L 10 003 WRITTEN NOTICE TO THE CER71MATE HOLDER NAMED TO THE I.M.8UT FAILURE TO DO 90 SAKLL iNPOSE NO 03LIG.ATION OR LMIUTY OF AMY KIND UPON THE MURER.ITS AGENTS OR TOWN OF B,ARNSTAAT•IC REFNSSBdrATIVES. .. - 367 MAIN STRZST AVfHORIXD REPRESEtUA-TIVE HYANNIS MA 02601 � fa7 ACORD.25(2009/01) 01988-2009 ACORD CORPORATION. All rWts resetved. The ACORD name and logo are registered maths of ACORD r r ✓lie �oovazoausealt/ a�../�aaaac�iva`Plt4 ,.� > Board of Building Regulations and Standards 1 License or registration valid for mdividul use only HOME IMPROVEMENT CONTRACTOR i before the expiration date. If found return to: Board of Building Regulations and Standards Registration 100497 One Ashburton Place_Rm 1301 j 1 Expiratjon 6/18/2010 Tr# 268012 r77 Boston,Ma.02108 i _. Type Pnvate Cprporation i DAVID COX INC+ David Cox .19 LAVENDER W.YARMOUTH;MA 02673 Administ Not valid without s 'naturerator y Y . . 11c SiltCt\ ' ldlttl7Cnt Ol Pnhstllnllilll� usetts-Dcl• ti•lnd ' Nlit�tiach �fulation `. lyd Of Bun SUP eryisor Ucense $O` con ctio �•` 63537. �icen5e CS { r #€ t 00 �t Restricted to;, OX` s .DAVID R C • PO BpX 4p1" MA 02664 S YARMOVTH a<:' 1C)1151VAA ZA�mz • Expiration 58 ' ��' ,tiioner • r r