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0027 OVERLOOK DRIVE
• ,���, .. �j ..� ].�. , :� , ,. f �' :.. 1.4.,y Y, a --5: .-� !' V' �1.�:t.;;: v(a it � 't ��M ,�� �.. ..r.:•...>b. �s.* ,.. .a�,h � .., ,: wt a5t. r. - i� ,r- ,. �:. •.�� r., ,. ,'a'�. h. t >r a e ,fa�' � F �,i,' Y• ,yy `t,�. it� �:,.` • �:... -. ,��:".t t„ �t....-.. �h...+r. ,l.W . .. r .:. �.• `N t6.' 'tf+ .� 'A".."i�' .�: :{,S',st 4 �A'�. '�• r}3S t. %,.�l'.�� '�S � L '.1' �rkl.:l� S V 1 k .', 3 � ':• 'ui"t {�4�`�3„�. ,s,��, ..,�� tiff '`�, { p WK 'C_ u 1f , v1 " [[ x p a o L� o y. 3 4 Y �• is f o , � t � r Ipu_5„A>..�� ,��—� v_ ..-:,.a.. ..........::.: �, ..._.... -. _ �•.. _�.,..._•t..,..........,,.. eJ..-.az,...a. .._e,. .......�...�...._ _.. .. .�. .r...�. i......-,�.-.. .�sa.,.-�.iw�r3-rsr� - Town of Barnstable *Permit# Expires 6 months from issue date ;,e£IN OF B,AR,H4 STABLE Regulatory Services Fee f VS s • •axr�srnsi.E, MA & Richard V.Scali, Director Building Division , Tom Perry,CBO,Building Commissioner ®PRESS PERMIT 200 Main Street,Hyannis,MA 02601 `V� MN www.town.bamstable.ma.us MAY 0 5 2015 Office: 508-862-4038 MI (�,� IV I4 �C EXPRESS PERT APPLICATION - RESIDENN"1`�i°�� U I C I (�{�O p; Not Valid without Red X-Press Imprint Map/parcel Number •- V +. t Property Address �� nUpt) Lme_ t)P _ _ Get-lr V_Q, (Y fir- G U (Residential Value of Work$ 1R,4,;�Q. Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address �4 i� Sri tL1-t f'lti�2`'.S c � �l1PaZ rI` �1R Gf` a ki[ 01 0�� Contractor's Nam,-<O f,. V/ : ram Telephone Number Home Improvement Contractor License#(if applicable) V_� ( l H Email: Construction Supervisor's License#(if applicable) rA Lj OU-) ❑Workman's Compensation Insurance Check one: [-Lam a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to \, kV0-7Cju'r ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) [Z Re-side VoJ y l._. ❑ Replacement Windows/doors/sliders.U-Value (maximum .35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License& Construction Supervisors License is req(uiir d. SIGNATURE: \ "' Q:\WPFILES\FO S\building ermit forms\EXPRESS.doc Revised 061313 40 Town of BarnstRble Regulatory Services Ch .Stara,Director coo Office: 508-962-039 Fax: 508-190-6230 r wn Must This Secuon.. complete anc, Igi. 1 -B m . � . . Us' g A -of the,s �CAI��rl abi=prop n all eis rem tw wow o by thmli :penrAtapt 407 #& g oob ' z f Date: Mist , t %in*forPerwAf. i wPlot.the err Lien 4emption Form On Me - Uviwd 05%1 01, I imassacthusetts DeparTme it of Public Board of Building Regulah,>nS ,incf Stan<fards Office of Consumer Affairs& Business Regulation , (' ui.truct1.,11 tinpcn n r ME IMPROVEMENT CONTRACTOR';: L,icense CS-014007 egistration: 101149 Type: d 7 !.Expiration: 6/2 512 0 1 6 Individual G John P Dunn $ P.O BOX#924 JOHN P.DUNN Marie Ann Terrace I Centerville MA 02632 John Dunn ,t 80 MARJE AN N TERR ./��+�- .�"y"` " . r:z i7 :in•i w � n 05/25/2016 f CENTERVILLE,MA 02632 Uene r d c etary i i Unrestricted-Buildings of any use group which -fi License or registration valid for individul'use only before the expiration date: If found return to: contain less than 35,000 cubic feet(991 m') Of - Office of Consumer Affairs and Business Regulation enclosed space. r 10 Park Plaza-Suite 5170 Boston,M A 02116 Failure to possess a current edition of the Massachusetts w j_... _.._........... State Building Code is cause for revocation of this license. '` Not valid without signature For DPS Licensing information visit: www.Mass.Gov/DPS a is The Commonwealth of Massachusetts Er� Department of Industrial Accidents ' ld Office of Investigations 600,Washington Street Boston, :YIA 02111 w,� wfv.mass•gov/dia k", r )i ontractors/Electricians/Plumbers ( 1 Workers' Compensation Insurance affidavit; Builders/ please Print Leaibl x . . p licant Information j �(,���" t� Narne (Business/Organiza!ior,/Individual): ti rt`�P� Address: C V `` h .Wfo3a- Phone,#: City/State/Zip: rate box: Type of project (required): ) Are you an employer? Check the approp 1 6 New construction 4. ❑.I am a general contractor and I 1•❑ I am•a emplover with have'h;red'the sub-contractors Remodeling employees (full and/or part-time' listed`on the attached sheet. t 8 Demolition 2.RL I am a sole proprietor or partner-' These sub-contractors have I . ship and have no employees workers' comp. insurance. i 9. Building addition working for me in any capacity. 5. We area corporation and its 10 Electrical repairs or additions o workers' comp. insurance (N offcers have exercised their 11,7 plumbing repairs or additions required.) right of exemption Per,1viGL 3.Q 1 am a homeowner doing all work c 152 §1(4), and we ave no 12.0 Roof repairs myself. [No workers' comp. employees [No workers' 1343.Qther�(t r insurance required ) comp. insurance required.) ensanon policy information. Any applicant that checks box#I must also fill out the section below showing their workers come olio information. tside t Homeowners wh o submit this affidavit indicating they are doing all work andhe ntame of theusub contractorosrand utheir work erse comp.dpvit i�dicaung such. tcontractors that check this box must at an additional sheet showing low is the policy and job site /am an employer that is providing workers'compensation insuracnce jor my employees. Be information. t Insurance Company Name: r Expiranon'Date: Policy y or Self-ins. Lic. n' ��aa c tt L c�(itfl Ciry/State/Zip: ( � 2rDyt�1 Job Site Address: ration Attach a copy of the wor kers' compensation policy declaration page (showing the policy ntimbefc nminaP'penaltieds of a onment, as well as civil penalties in the form of a STOP doo the'Of Of a fine Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition fine up to S1,500.00 and/or one-year imp of this statement may be forwarded of up to S250:00 a day against the violator. Be advised that a copy investigations of the DIA for insurance coverage verification , l provided above is true and correct I do hereby certify tin er the pains and penalties of penury that the ir.Jo.matron .Date: Si azure Phone #: Official use only. Do not write in this area; to be completed by city Or town of Permit/L,icense# City or;Town: Issuing Authority (circle one): _ of Health 2. Building Department 3. City/I'own Clerk 4. Electrical Inspector 5. Plumbing Inspector 1. Board - 6. other _ Phnne =: ii i TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map / Parcel Application #CYUr_�% Health Division Date Issued r Conservation Division Application FeeqLs Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project gStreg� Address 1/ Village L�At4v�l 'f/` 0�� Owner f iX4 ��1,0�/� Address Telephone 611 _ 1 2-3-O U Permit Request t %let,k//vama/u tv-) - &44 kl-w&V 1060 R111 1�047fo &A9 A�w 'a1-/- hial awl 6 Cy/w Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay --a Project Valuation �3�` Oronstruction Type_. 4 Lot Size - Grandfathered: ❑Yes ❑ No If yes, attachsupportinWcLtentation. t Dwelling Type: Single Family C/ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highwa:? ❑Y�_s ❑•No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑Other 03 v : 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/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size — Other: Zoning Board of Appeals Au "orization ❑ Appeal # Recorded ❑ Commercial ❑Yes ®'No If �es site plan review# Y Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name ili6 �� G� Telephone Number Address/4&� —�; License # G Home Improvement Contractor# Worker's Compensation ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WIL BE TAKEN TO SIGNATURE DATE �` 7 ( / FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED I MAP/PARCEL NO. li ADDRESS VILLAGE OWNER DATE OF INSPECTION: ;Y j-FFOUNDATIONi,—.,,t:.z.ix-4i,d 'J:-9u„ -.-,,;,.,. , s FRAME i I ' n INSULATIOW, FIREPLACE { ELECTRICAL: ROUGH FINAL -" i PLUMBING: ROUGH FINAL i GAS: ROUGH FINAL It FINAL BUILDING" . ,e DATE CLOSED OUT ASSOCIATION PLAN NO. =y'• 1litss ki,'IIkI e Cs Dcp u•inunt ut Pullllc ):(Vcl\ liu,lrtl. ul Utiiltllit ]:c ulati tn,'mid M,tltil;u 6 i�onstrl_I,P on Supervisor Licetisa t_ic.cn�..' C.S.w 'IUU9r38 ' " Nl" h HEMRY CASSIDY t� d SHED ROW WE3j_ YARMOUTH, MA 02673' Expiration:-11/1ll4U13 Ti s: 1420 � 10��1.��GCz-j�f• 0(1(rl 1 Czr > '�L:C� J,1C. �C.�111�!(.'f l U. I; Off ce,„o Cons imer Affairs and Business Reputation I I 10 Parts Ptaza Suite 5170 Boston, Massachusetts 02146 1-1 61 -te,Yrnpro`!ement Co11t1'aetor 1 egistration Registration: Type. Private Q Uiporatiull Expiration: 12/'Ia/A11 Trt{ 2J;itlJI COO INSULATION, INC q iif_'NRY CASSIDY Id REARDON CIRCLE SC) YARMOU I f=1t MA Q' 66 1 Update Address and return curd.,Ntarlt rtiaouu fill:cluulge. Address Ll Renctval It:nit.iluyntuliit I I,u�t l',lid ... 'r�. �li l�irr Ncn Nt e.'rFlrrfl (�.C-.:F�((t,1J!!t%!l(,1 c•���J � -: . :•, _.� _ �. ,_, t 111,4,(d l inlstimer Arnlit ti S Business ttt gul;uitill Liccnsc ul rcgistratiun valid Cot individul we,uuly IMMKO.V MkNT CONTRACTOR befult,the cxpiratiun last 1f fuuIldwrcturu lo: .;.1 uyisuati0tt: 1535ti7 `" "YP✓ Ufk of Cunsunlet Attvlr's and Business Regululiuu . i&; 10 furl Plaza Suite 5170 ' xpIIaIIo11: 1</15/2014 Prlvat� Corporation - B Tutu tt,4'l A.Q2 l 1G n1 -A'11 N, INCf 1 --1 I a 0 V� ittlu� iat;f? l II br ?)).! Lj Aid e1sec e[itry t,e , - - Vill' wit + 1 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Iinsurance Affidavit: Builders/Contractors/Electricialns/Plumbers Ap ficant Information ]Please Print Le2lbty Name (Business/Organization/Individual): Address: -- City/State/Zi z G G Phone #: 6F 71Z_� Z 144 Are you an employ r? Check the appropriate box: l. T am a employer with._,t 4. I am a general contractor and I Tie°f project(required): employees (full ancVgr Part-time).* have hired the subcontractors 6. ❑ New construction 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. T. Remodeling ship and have noemployees These sub-contractors have g. Demolition working for mein any capacity. employees and have workers' [No workers' cornp. insurance comp. insurance.; 9. ❑ Building addition required:] 5. [] We area corporation and its l0.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself [No workers' comp. right of exemption per MGL insurance required.] t c. 152, §1(4),and we have no 12.0 Roof repairs 3a.11 I am a homeowner acting as a employees. 13.LYOther f,fi� L� 6� general contractor(refer to#4) [NO workers' ii comp:insurance required.] "Any applicant that checks box#1 must also fill out the section below showing their workers'compcnsatioiipolicy 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. tConttacton 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 worker'comp.policy number. !am an employer that is providing workers'compensation insurance for my employees. Below is the policy site information. p c3'and job l Insurance Company Name:_ Policy#or Self-ins. Lic.#: �Z Expiration Date: l �d Job Site Address:_ �� pw I n / City/State/Zip: �f�le, 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 fine up to S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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 cernjy nde7j*e nd penalties of perjury that the information provided a ove is true and correct Date: V2 t Phone#: [66. icial use only. Do not write in this area, to be completed by city or town official y or Town: Permit/LIcense# ing Authority(circle one): I. oard of health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector thertact Person: Phone#: I i CAPECOD-27 MYOUNG CERTIFICATE OF LIABILITY INSURANCE F)ATE(MMIDD/YYYY) .ATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS7/8/2013 c DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THEN COVERAGE AFFORDED BY THE POLICIEIs S THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED .SENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. JR If i certificate holder is an ADDITIONAL le termsms and conditions of the policy, INSURED,the policAies)must be endorsed. If SUBROGATION.IS WAIVED,subject to a certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate_holder in lieu of such endorsement s). PRooucEH License#PC-514062 �NAME:rorncT Rogers&Gray Insurance Agency,Inc. Margaret Young 434 Rte 134 ONESouth Dennis,MA 02660 C a AICNu)_�_ EMAIL - - " ADDRESS:m oung rogersgray.com INSURERS AFFORDING COVERAGE NAIC p �INsulll=_D msURERA:PEERLESS INSURANCE CO(VIPANY ' INSURER 13:COMMERCE INSURANCE COMPANY Cape Cod Insulation,Inc. INSURER C:Evanston Insurance Company _ 18 Reardon Circle INSURERD:ATLANTIC CHARTER INSURANCE GROU South Yarmouth,MA 02664 P INSURER E:. COVERAGES _ INSURERF: CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FQR THE POLICY PERIOD INDICAIED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS I CERTIFICATE.MAY BE ISSUED'OR MAY PERTAIN , THE INSURANCE AFFORDED BY THE POLICIES EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, IN SR ___.—..—�.._ AD15L SOER LTR TYPE OP INSURANCE• POLICY EFF POLICY EXP. POLICY NUMBER MM/DDIYYYY MM/DD/YYYY - LIMITS GE - A X COMMERCIAL GENERAL LIABILITY� CBP8263063 EACH OCCURRENCE ` $ �_1,000,000 4/112013 4/1/2014 FTO_RENTEO CLAIMS-MADE Cx J OCCUR PRE ES Ea occu once $ 100,000 MED EXP(Any one porson) $ `5,000 — —" PERSONAL&AOV INJURY . $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 _GEN L AGGREGATE LIMIT APPLIES PER: —•------ -_�__ PRO- F__j PRODUCTS-COMP/OP AGO $ 2,000,000 I POLICY�ECT I I LOC -- .AUTOMOBILE LIABILITY - $ - _ C MBINED SIN L LIMIT B. Ea acddent 1'000,000 ANY AUTO 13MMBCKVMK 4/1/2013 4/1/2014 BODILY INJURY(Par person) $ ALL OWNED x SCHEDULED _ AUTOS X AUTOS --— cGdenl) $ X hilRkD AUTOS X NON-OWNED AUTOS PROP TY DAMAGE ER ACCIDENT $ )( UMBRELLA LIAR X O C EXCESS LIA9 _CCCUR - EACH OCCURRENCE $ 1,000,000 LAIMS-MADE XONJ453512 X RE r�NT10N 4/1/2013 - 4l1/2014 AGGREGATE - 1$ -- - ,000,000 $_ 10,000 WORKERS COMPENSATION AND EMPLOYERS'LIABILITYSTATUS OTf1- D ANY PROPRIETOR/PARTNER/EXECUTIVE Y r N WCA00525904 6/3012013 6I30/2014 -- OFFICEktMEMaER ER EXCLUDED7 N/A E.L.EACH ACCIDENT $ 1,000,000 (Mandatory In NH) It yyes,dascriba under E.L.DISEASE-EA EMPLOYE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 L....._I_......_._ ..- -- -DESCRIPTION OF OPERATIONS r LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) '— Workers Compensation includes Officers or Proprlectors. Addtional Insured status is provided under the General Liability when required by written contract or agreement with the Certificate Holder, CERTIFICATE HOLDER CANCELLATION - I SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cape Cod Insulation,Inc THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25(2010/05) 01988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD OWNER AUTHORIZATION FORM (Owner's Name owner of the property located at 2 7 & I/Pr /ljG �/'� ✓Q (Property Address) (Property Address) hgreby authorize Subcon rector) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. er's ign e /I c2A9 Z5 Date CAPE Cog N S U L A T 1 O1i1 P�"'C 'E p€4 1; PIYER Q-A S SEAMLESS SPRAY FOAM SUSPENOEO GATTS OYTT[YS INSUIPTION Cftli IO- _ 1-800-696.-661 Town of Barnstable Regulatory Services Building Division 200 Main St Hyannis, MA 02601' Date: Dear Building Inspector Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed & completed the insulation and weatherization work at the property listed below. Cape Cod Insulation did this in accordance to the specifications listed on the building permit application. All work has been inspected by a certified Building Performance Institute (BPI) inspector. All work preformed meets or exceeds Federal & State Requirements. .I . Property Owner Property Address Village Tcj , �- 5Actk�tiQV� �� 0VU-10v<< 1� Insulation Inst alled. Fiberglass ass .Cellulose R-Value Restricted Unrestricted g I i Ceilings Slopes Floors f C at-<.2 Walls SPuc.n Sincerely 4 HjE Cas y Jr, President CCod I ulation, Inc. �oFr►fr��y Town of Barnstable *Permit# ti Regulatory Services Expires 6 molu r onr iss 'date s•gRVSnM LE, " Fee y uASS. 1619• Thomas F. Geller, Director lilt Building Division Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town,barnstab le.ma.us Off—ice: 508-862-403 8 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Fax: 508-790-6230 i / Not Valid without Red X-Press Imprint Map/parcel Number 1 Property Address a4 0-k1--?tU-�� [Residential Value of Work Minimum fee of$35.00 for work under'$6000.00 Owner's Name & Address ---,�� Contractor's Name n��;� , -� -� (/—�'/v `s Telephone Number . Home Impro,0ement Contractor License#(if applicable) Construction Supervisor's License#(ifappl;icable) r--j ` ,.-PRESS PERMIT ❑Workman's Compensation Insurance NOV a. 2010 Check one: ❑ I am a sole proprietor TOWN OF E3P+RNSTAE�LE ❑ I am the Homeowner ❑ I have Worker's Compensation.Insurance Insurance Company Name Workman's Comp. Policy#_ —,-)71_�- Oftku 4 do 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 rood ❑ Re-side R lacement Wrn #of doors do-rvs/doors/sliders. U=Valtie_ ' (maximum .35)#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. equired. 3IGNATU121;; ?AWPFILESTORMSIbui 'igpermit formslEXPRESS.doc Zevised 072110 r� The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 �r www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLyibly Name (BushTess/0rganization/Individual): 7 ,5 Address: c-ratiberr,.4ZOO City/State/Zip: /hA Phone L�Qoo Are you an employer?Check the appropriate b x: Type of project(required): 1.❑ I am a employer with A I am a general contractor and I 6. New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 1 7• Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity, workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We area corporation and its required.] "officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] t 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. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'.comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Mors 1 Policy #or Self-ins. Lie. #: 0C ,Z6y � Expiration Date: Job Site Address: 1861<1 City/State/Zip:f�M feru l �> . 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. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct: Si nature: Date: ' (� Phone#: 7 P 0,06 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 employbes. Pursuant to this statute, an employee is defined as "...every, person in e service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual, partnership, association corporation or other legal entity, or any two or more of tl-e foregoing engaged in a joint enterprise, and including the l gal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or o er legal entity,employing employees. However the owner•of a dwelling house having not more than three apartme sand who resides therein, or the occupant of the. dwelling,"house of another who employs persons to do mainten nce, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not be use of such employment be deemed to be an employer." MGL chapter,�152, §25C(6)also states that"every state or I cal licensing agency shall withhold the issuance or renewal of a Dense or permit to operate a business or to onstruct buildings in the commonwealth for any applicant who has not produced acceptable evidence of mpliance with the insurance coverage required." Additionally, MG�L chapter 152, §25C(7)states"Neither th commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work ntil acceptable evidence of compliance with the insurance requirements of this hapter have.been presented to the co tracting authority.". Applicants Please fill out the worker ' compensation affidavit compl tely, by checking the boxes that apply to your situation and, if necessary,supply sub-contr tor(s)name(s), address(es) d phone number(s) along with their certificate(s)of insurance. Limited Liability panies (LLC)or Limite Liability Partnerships(LLP)with no employees other than the members or partners, are not requ' ed to carry workers' c mpensation insurance. If an LLC or LLP does have employees, a policy is required. Be dvised that this affi vit.may be submitted to the Department of Industrial Accidents for confirmation of insuranc coverage. Also Pe sure to sign and date the affidavit. The affidavit should be returned to the city or town that the ap lication for the'permit or license is being requested, not the Department of Industrial Accidents. Should you have any .uestions regfrdmg the law or if you are required to obtain a workers' compensation policy, please call the Departm t at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriat line. City or Town Officials \da PAPlease be surethat the affidavit is complete and p _legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the f Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number 'll be used as a reference number. In addition,an applicant that must submit multiple permit/license applicatioany i.ven year, need only submit one affidavit indicating current policy information(if necessary) and under"Job Sdress- e applicant should write"all locations in (city or town)."A copy of the affidavit that has been officiamped o marked by the city or town may be provided to the applicant as.proof that a valid affidavit is on file foe permits o licenses. Anew affidavit must be filled out each year. Where a home owner or citizen is obtaining ase or permit n related to any business or commercial venture (i.e. a dog license or permit tobum leaves etc.)saidn is NOT requi d to complete this affidavit. The Office of Investigations would like to thank yovance for your coo ration and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Common ealth of Massachusetts Department f Industrial Accidents Office l f Investigations 600 Wjashington Street. Boston, MA 02111 --- Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia esiru- t.0 to u:y: rJ INSTALLS !Y!p P 2;4 Ike ornmo Wallh of-Massuchusetts Department of Industrial iccftlerrts df ce of nvt'stiggva ns j 6lt0Washingivte Street wrvw nr�ss.govlriarr Wor`kers5 Compettsatto�`ltxsuranlce A# davuilcletps/ ontrcoa-sllctriciat>islPltem A iteant l`ttfo,rtn.a.tio bars f I vas a Print Name (Has n�esrt)rganlzatiori/tndtvidua �,3 /_3- do t Ptlofie #: �� 2 7 e/ — y� Z _ Arc v:ou art tmptoy�er.>Chick the appropriate box: i �"I am a e►nployer with /--�`, 4. gene't81 contractor and t f Pniect(required`-}:—�� Type o cmptoyees(full and/or part tttnG},+ have hired the sub-egntraclors 6. ❑ New construction 2 ❑ l::am a sole proprietor orpaener-,. listed an Fhe:attacheei-cheek: 7. { Rctitodclint SNP—and'llavc naemployees These sub-contractors have working for me[n any capac(ty emp.loyces and have woiket ' ' :❑Iaen�oEition [No workers ,Comp 1115urarlre comp rnsur;3nce i 4, ❑Building additioa7 requtrezi} 5. a We are a corporation and its 10. ❑1 lectriml repairs,or additions 3 ❑ I ►m a homeowner doing°all work. 0Efeers have.eaeri iced their niyseif (Nu workers com}i right of eaempGon'per MGL l ittml;lr, repairs or adtilttonS in.suranc.e:r utred. P C. i_52, ! 4. and>w have no 12.0 Roof repairs employces.'(No woikcrs' 13.0 other comp tnst<rarRcr required.} -- triny applicant that Chicks hux d! iriusi also flit teal the serKrpn below Sliuwfng Iltei�Workers'c ontlkttsatian policy igi�tettlFion. t':11Un1SS,WrICr3 wren_sullmtt Eh tS at�rilRvtl;rrrdiCarutg th[�+arc dUing.All Wtirk 8nt1 then hlri p{ilSidC GonileClp[S nllf5t SUtStTiii u n[w T}Klavit indicating SE1CI1. CunhaCtof3!65!Check Ilea box must alisehpd adde;et+nEl 9heat 9hpwing the natix of the tub�,.ontrnctors and�Yatr:whntieer�jr nUt thies eniities hive Ciopi4:yeas;if the Sut i nntraeturs have eept�y�eg they must pr4xade ihr u veorkef5 cortip;:isoiiq number, I aria an:errrptaver i jot.rs.'pra►�r�irr to prk rs'cp»pensatian ansutrYtrc e for my rmplalyees'Below is the policy_arid jab site tnf8rnrtillO>l. lt>Sursrtt c Company Natrie lZ Qs� i, PoF-TYJ.or etf-ins Llc't! // bxpiraFian Date; _ !ob 5tte,4 Gress: G�C1 l C tylStattlZip f 2.� 4ttach a'copv of the wtirktrs'rontiltusatlon'pttlicy dr laratioil`ptige(show O'g the policy number oriel expiratioai date). 1 allure fo:securr Luvcrae a5 requtrod undo Section 25A of 1vtGL c. i52 can lead tv the iuipasitivn oFcrromutartrtialtics olio F. fine up to-S! SO4-ata amilt r one year imprisorunent as wt!!as civil penalties in the for ofa STOP WORK ORDER and a Fine o up to 250 OO a tiny against the vlolii& be advised that a copy of this statement may be forwarded to the Duce or lnvest19ations o:fthe DIA fur'insurance cover-11v rrficaf on J:do herxby certify undr rA ptaW and `ena�lnes:of perfury that the info rth arinn provider!above is rraae and correct Elate: ���e Phone# t?firirtl ucr D t yet wtile an t IS urea, 0;' cvmp ,w AP city or low"ofl'iciat l;sry tir"Cowin PermittLlcease>Y issuing Authtirit .(circtc 1 Board of Health �'13utid rig department 3 Cit,rr jv(t Clerk 4i Electrical inspector 5. Plumbing.lnsptctor 6 ttb'er. CUntgct f crso.v Phoaae#: — ---- Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registratiorv:-,�;148688 10 Park Plaza,-Suite 5170. . ExpiratiDR ?f7fx$2011 Boston,MA 02116 3 :y Supsiement Card LOWE'S HOMES CEW:ERS1#SIC''' JAYMI RODRIGUEZ"=; 136 TURNPIKE Rb-SIN T€A00 g SOUTH BOROUGH,MA 01'772 Undersecretary Net.-valid without signature -. t A R ® O CER FIiAAT E OF LIABILITY INSURANCE1 DATE DDYYW) ----11/4/10 THIS CERTIFICATE IS ISSUED AS A MATTER OF.INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR•NEGATIVELY'AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER::: IMPORTANT: If.the certificate holder is an;ADDITIONAL INSURED,the`pollcy(ies) must be endorsed. 1f SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require ah endorsement. A statement on this certificate does not.confer rights to the certificate:holder in lieu of such endorsemenf(s). PRODUCER NAM11E: Christal-Johnson Robert E Bouchie. Jr.' Insurance. IALGo ExU..-{5081__564-5560� _ FAX NE Robert 564_5531 1352 Route 28A EMAIL - ADDRESS: 'info@Bouchielnsurance.com .-PO -Box 400 PRODUCER:_— -- —__CUST.OME R I D.#: 1326 .. ... Cataumet, MA 02534 INSURE ,R(s)AF . . .. ,,..... FORDING COVERAGE .. _. NAIC# ` INSURED INSURERA:At:lantiC;„Casualty Insurance Co.. 42846 ,BBL Home Improvement LLC. INSURER.a Pilgrim Insurance Co , 21,750.. =48"Rook Gutter Street IN JRERC AmGaurd Insurance. Group _ ... Middleboro, MA 02346 : INSURER0: :. . INSURER E; INSURER F COVERAGES _ _ CERTIFICATE NUMBER: _ REVISION NUMBER: THIS.IS TO CERTIFY THAT THE POLICIES OF INSURANCE:LISTED BELOW HAVE BEEN ISSUED:TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD )NDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICA'r.E MAY BE ISSUED OR MAY.PERTAIN- THE- INSURANCE AFFORDED.BY'THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSION'S AND CONDITIONS OF SUCH POLICIES..LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. - INSR; 'ADDLSU,BR - POUCY EFF ` 'POLICYE 0 LTR TYPEOF INSURANCE - INSg POLICY NUMBER (MMIDD/YYYY) (M!NDDIYYYY) L1AilTS : GENERAL LIABILITY , EACH OCCURRENCE 1,000,000 I �,A, }� ..COM\9ERCIA!:C,Eiv'CRAt1.lABIU1'Y - - .L123000579 4./7/10: 4/7./11 D�M RENTED S GE TO REN ISES(Eaoccurrence).. 50_,_000. _. j CLAIMS•h1ADE X f OCCUR .. :1:SE0 EXP(Aiyorie Imrscn) S 5.1.00.0 . - - PERSONAL&ADV INJURY S 1,,OOO,OOO ., .. .. i GENERAL AGGREGATE 5 2.,QOO r OOO GEN'L AGGREGATE LIN-11TAPPLIESPER PRODUCT'S•(O1.4S'tOP F:GG S 2,000,000 PRO- . -X;POLICY EGT LOC AUTOMOBILE LIABIUTY - CONSINE)SINGLE LIMIT B ANYAUTO PGCOOOl00.7975 4/10/10 4/10/11; (Ea aced n,') BODILY INJURY(Per Fx rson) S100,000 BODILY INJURY(Peraccident) 'S 300,000 }{ SCHEDULED AUTOS PRPERTYDAIMGE X (IREDAUTOS 100r000^ I X.NON Ot±dNEDAUTOS 5 :UMSRELLA LIAR; j OCCUR _—._—•--_ -- `EACH OCCt1RRENICE S - EXCESSLIAB C; --S-AaADE AGGREGATE s' DED UCTlB LE S RETENTION `5' WORKERS COMPENSATION — U:C STA1'U 'OTH C BBWC121597 4/25/10 4/25/11 X ER ; AND EMPLOYERS LIABILITY TofzYl-1n4ITs YIN - ANYPROPRIETOR)PARTNERr'EXECUTFVE EL h.ACHACCIDENT S 1,000,000 . OFFICE R4V;Et11BEREXCLLOED7 I NIA... (Maixiatwy in NH) _, '—` E L DISEASE EA EtviPi.OYEE 8 1,000,000 If yes,describe under DESCRIPTION Or OPERATIONS Ueio.v E L DISEASE-POLICY LIMIT S 1,000,000 � _- - DESCRIPTION OF OPERATIONS I LOCATIONS l VEHICLES.(Attach ACORD 101,Additional Rennrks Schedule,if more space is requ red) Manuel S Barrios is included in his Workers 'Compensation Coverage, Fax,: 781-271-.2009 Attn: Kent'. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE A13OVE DESCRIBED POLICIES BE CANCELLED BEFORE _,THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Lowe.'s ,Home.Center;. ACCORDANCE WITH THE POLICY PROVISIONS. 32 William 'C Gould Way _ �— 'Kingston, MA 0.2364` AUTHORIZED REPRESENTATIVE ' - - --- - -------- ------ .lRobert E Bouchie Jr. -- - ' ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25{_2009J09), The ACORD name and logo are registered marks of ACORD 7 . .I 20.10-10-11 11 :21 » 1663 ISO P 11/11 o�IMi Town of]Barnstable Regulatory Services MAS& Thomas F. Geiler,Director ib39• Build>iug Division. Tom perry,Bufldi#g Commissioner 200 Main Street,Hyia s,MA 02601 �ww.town.barnstable.naa.us office: 508-862-.403$ Fax: 508-790-623 Propert Omer Must Complete and Sign This Section p If Usin . A BOder as OvIlier'of the subject property hereby autho to act am my behalf, ul a1�matters rsJative to work authorized bythis buEding permit application foz- aL&k (6dress 0 job) gnature of Cr �- T'rult 1�ame if Z'-opexty_I� er is.applying for pelt please complete+the oxxae©one Upense Exemption F� on the•reverse side' �f� °"""'A4�u�i es o�i License or registration valid for individul use only Office o o Sumer HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: ,153118 Type: Office of Consumer Affairs and Business Regulation Expiration: tW�9Q 2012 DBA 10 Park Plaza-Suite 6170 Boston,MA 02116 k9BHOME IMPRQVC 1 MANUEL BARRO$JR R};�r 48 ROCKY GUTTEf'� MIDDLEBORO,MA(f236 Undersecretary w, ou Mary L. Chabot . ®® 12 Thompson Rd Webster MA 01570 ® • 508 826 5757 RRPEPA.com �� ��� Certificate of Attendance and Completion Renovator Initial per 40 CFR part 745:22 a Manuel Barros Jr; ti 48 Rocky.Gutter.St: s „ Middleborough MA 02346 Course&Exam Date 3/04/10 k pExiration Wte:3/04/15 x , a% i f li Certifi6ate#R1-18867-10-00184 Date: x License or:registra y Bodrot`�tf(iTdof(s�d �Tat�a tion valid for mdividul use only HOME IMPROVEMENT CONTRACTOR 4 before the expiration date: `If found'return to: Board of Building Regulations and ;Standards Registration 1531 i8 One Ashburton Place Rm 130.1 Expiratioh` 10/30/2010, Tr# 275148 Bostor►;Ma.02,108,: B B.L.HOME IMPROVEMENT } 4 MANUEL BARRO JET"k 38 CHARLOTTE FURM17RCE W.WAREHAM MA 0257� Administrator it'wt atul'e� , �f ' Yl�tssachusetts pttc nt "�`uhhc Safety Restricted to: oo R Board of Builtlrt Rewlatiflns tl Stanclar E Consl7 uct6n supervisor License 00- Unrestricted , 4 52157 I- 1 2 Family Home' s {r{ j' Ltcer 'r C I i�, Resti•icte�.� � ,,s � � k MANUEL.&'BARROS,JR' x v 38 CHARLOTTE FURNACE RDA Failure to possess a current edition of the iArl .. `� W VVAREHAM MA B2576.. Y Massachusetts State BuildingCode " is cause for revocation of this license. � � Expiration:.7117/2011 Refer`to:' WWW.Mass.Gov/DPS Tr#:.17850 S Yt '.l b 3 k r M TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION. Map Parcel Application # {{ Health Division ""Date Issued Conservation Division Application Fee C)..'. Planning;Dept: 'Permit Fee Date Definitive Plan Approved by Planning Board Historic OKH _ Preservation / Hyannis r Project Street Address" Village ` � Owner= --�-- dreass 2 Telephone_—__ — . 3 '- �,F l Permit-Reques Alevw Square feet: 1 st floor: existing proposed `2nd floor: existing proposed Total new Zoning district: Flood Plain Groundwater Overlay ,I---Proj ect Valuatio n Construction Type „ a .-. . Lot Size Grandfathered: 0 Yes ❑ No If yes, attadhMsupportir(g:doc=entation. ,ate; Dwelling Type: Single Family ,;0 Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King' Highwe�E ❑fl& ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other -0 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/coal stove: ❑Yes ❑ No Detached garage: ❑ existing 0 new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new 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 I TI (BUILDER HOMEOWNER) --Tele hone•Number�_6_ p A Address_,® CT�Z ��-� License # P Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEB !ESULTING F HIS PROJECT WILL BE TAKEN TO SIG E E� i FOR OFFICIAL USE ONLY APPLICATION# i DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER r DATE OF INSPECTION: FOUNDATION FRAME PRow► &121101 INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL p PLUMBING:. ROUGH FINAL ;C GAS: ROUGH FINAL FINAL BUILDING C-15101 ti DATE CLOSED OUT ASSOCIATION PLAN NO. y The Commonwealth'of Massachusetts Department of Industrial Accidents x Office of Investigations' 600 Washington Street Boston, MA 02111 www.mass.gov/dia Yorkers' Compensation Insurance Affdavit Builders/Contractors/Electricians/Plumbers Applicant.Information Please Print Le ibl Name (Business/Organization/Individual): fl/ C/ Address: �itZt "ee_g1 City/State/Zip: V' A& Phone.#: Are you an employer? Check the appropriate box: Type of project(required): 4. I am a general contractor and I 1.El I am a employer with employees (full and/or part-time). * have hired the sub-contractors 6. ❑New construction 2. listed on the attached sheet. T. Q Remodeling I am a soleproprietor or'parttier-' ship and have no employees These sub-contractors have g, 'o Demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers'•comp.-insurance comp. insurance.t 5. We are a corporation and its '10.[] Electrical repairs or additions equired,] � ' 3 am a homeowner doing all work officers have exercised their I LE]Plumbing repairs or additions // myself. [No workers' comp. right of exemption per MGL 12T]Roof repairs insurance required.] t c. 152, §1(4), and we have no employees.[No workers' 13.[� Other comp.insurance required j *Any applicant.that checks box#1 rust also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tConbmctors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of crimui4l 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 insurancee0eraize verification. I do hereby certij�un r the pai nd enalties of perjury Date: that the information provided above is true and correct Si afore: — Phone Official use o - . Do not write in.thts 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#: �� rty;• Information and Instr'ncti®ns Massachusetts General Laws chapter 152 requires all employers to provide workers' compensationfor their employees. Pursuant to this statute,an employee is defined as "...every person in.the service of another under any contract of hire, express or implied, oral or written." An employer is d med as"an individual,partnership,asso* ation, corporation or other legal on or any two or more of the foregoing on ed in a joint enterprise,and inclu ' the legal representatives of a deceased employer,or the receiver or tiustee of ' dividual,partnership, associati n or other legal entity,employing employees. However the owner of a dwelling house g not more than three a artments and who resides therein, or the occupant of the ploys persons to do intenance, construction or repair work on such dw dwelling house of another who elling house or on the grounds or building app nant thereto shall of because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states th t"every st a or local licensing agency shall withhold the issuance or renewal of a license or permit to operate busines or to construct buildings in the commonwealth for any applicant who has not produced acceptab. evide a of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7) state "Nei or the commonwealth nor any of its political subdivisions shall . rformance of pu lic ork until acceptable evidence of compliance vrith the insurance enter into any contract for,the pe requirements of this chapter have been presented to e contracting authority." Applicants Please fill out the workers'compensation affidavit omple ly,by checking the boxes that apply to your situation and, if necessary,supply sub-conti'actor(s)name(s),�addres (es)and. hone number(s) along with their certificates)of insurance. Limited Liability Companies•(LLC) or imited Lia 'lity Partnerships(LLP)with no employees other than the members or partners, are not required to carry wor erg'compens on insurance. If an LLC or LLP does have employees,a policy is required. Be advised that s affidavit may e submitted to the Department of Industrial Accidents for confirmation of insurance coverage Also be sure to s n and date the affidavit. The affidavit should be returned to the city or town that the applicano for the permit or lice e is being requested,not the Department of Industrial Accidents. Should you have any ques ions regarding the law o you are required to obtain a workers' compensation policy,please call the Departure at the nuntber listed below. Self-insured companies should enter their self-insurance license number on the appropri e line. City or Town Officials .Please be sure that the affidavit is complete' nd printed legibly. The Department has ovided a space at the bottom of the affidavit for you to fill out in the ev t the Office of Investigations has to contact u regarding the applicant. Please be sure to fill in the permit/license umber which will be used as a reference numbe In addition, an applicant that must submit multiple permit/license pplications in any given year,need only submit one idavit indicating current policy information(if necessary)and un or"Job Site Address" the applicant should write"all to lions in (city or town).".A copy of the affidavit -- has een officially stamped or marked by the city or town may ,provided to the applicant as proof that a valid affidavit 4on file for future permits or licenses. A new affidavit must be`fiIled out each year. Where a home owner or citizen is o�raining a license or permit not related fo any business or commercial venture (i.e. a dog license or permit to burn leave etc.)said person is NOT required to complete this affidavit 111� a The Office of Investigations would no to.thank you in advance for your cooperation and should you have any questions, .please do not hesitate to give us a call. The Department's address, telephoae•and fax'nF-�Ar-: The Commonwealth of Massachusetts Departrn.ent of Industrial Accidents a � �f Office of Investigations. 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 n Town of Barnstalble , o Regulatory Services � s Thomas F. Geiler,Director MAS& 9q,A 16j9. Building Division T6n µat" 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: ©� ® Al JOB LOCATION: number / - street village .,HOMEOWNER": name home phone# work phone# 3. CURRENT MAILING ADDRESS: ? kp- cityltownP-tef �� state zip code The current exemption for"homeowners"was extended to include owner'occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. T DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is,or is intended to be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum ' e lion procedure iru ements and that he/she will comply with said procedures and require tints. ignature of Homeow Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a-licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,.many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certifrcation for use in your community. Q:\WPFILES\FORMS\homeexempt.DOC THE 1 � Town of Barnstable Regulatory Seryices � k• �nx ASM E. Thomas F. Geiler,Director � ncaes. �' / 039. �� Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 WWWAown.barnstable.ma.us Office: 508 862-4038 Fax: 508-790-6230 Property er Must Complete and ign This Section. If Us in A Builder \\,\L , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work aiith rued this building permit application for. (Address of Job) Signature of Owner Dat Print Name If Property Owner is a-'-PPlying for permit please e � Homeowners License Exemption Form o e reverse si e. Q:FORMS:OWNERPERMISSION k- ;e__�...�... �� ,� f `� - �,� ti � ,.1�� a �. q. � � �` �' �� �,� �(/Jive ��v��`� � }_ � ���, � � � ��i- _ � . - # � � �� . C�� � _ Q� � . E i . . - �- �� . L �: A ///JJJ - } . ... _ � F +hr III/ 1 �I I 1 I+ r ����� '. _ � .. 1n'��� V- / .. .,, 1.. _ .. _ .. .. I I ., . ..�