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- oFt�rqy, Town of Barnstable *Permit#�W%()S
Expires 6 onths from issue date
, y. r,g, Regulatory Services Fee
v HAS& Thomas F.Geller,Director
�ArEn 39. -PRESS PER - ' ding Division
FB Tom Perry, Building Commissioner
2009200 Main Street, Hyannis,MA 02601
Office: 508-86 8N OF BARNSTABLE
Fax: 508-790-6230
EXPRESS PERNIIT APPLICATION - RESIDENTIAL ONLY
i ' �j Not Valid without Red.-Press Imprint
Map/parcel Number a �l O 3 -
Property Address 315�
tesidential Value of Work
Owner's Name&Address d1C)1�L�Ott1 on i- Wmoo 0
Contractor's Name° Jp�tV1 , R � �� Telephone Number
Home Improvement Contractor License#(if applicable) [022
Construction Supervisor's License#(if applicable) Lk ZS
` Jorkman's Compensation Insurance
Check one:
❑ •I am a sole proprietor
I am the Homeowner
I have Worker's Compensation Insurance
Insurance Company Name ky
W-orkman's Comp.Policy# "1UU (-Aq L-t l?.06 9
Permit Request(check box)
❑'Re-roof(stripping old shingles) All construction debris will be taken to
❑Re-roof(not stripping. Going over existing layers of roof)
<�cl
❑ Re-side' akk .5cLVV P- -50'_m�
Replacement Windows. U-Value +0 (maximum.44) P���c, v�.i Acid
*where required. Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: -ram. er must sign Property Owner Letter of Permission.
on.
ement Contractors License is required.
Signature
Q:Forms:expmtrg
Revise053003
The Commonwealth.of Massachusetts
�\ Department o Industrta Accidents
Office of Investigations
' 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plunibers
applicant Information Please Print Legibly
lame(Business/Organizationdlndividual):
.ddress:
'ity%St e/Zip: Phone.#`:
gain
an employer?Chec a appropriate box: Type of project(required):
a employer with 4. [] 1 am a general contractor and I 6 []New construction
employees(full and/or part-time).* have hired the sub-contractors
listed on the,-.attached sheet. 7.' ❑Remodeling
] I am a sole proprietor or partner- These sub-contractors have
ship.and have no employees 8: ❑Demolition
working.for me in any capacity. employees and have workers' 9 Building addition
[No workers comp. insurance.#
comp.insurance 10. Electrical repairs or additions
required.)qu 5. [] We are a corporation and its. ❑ p
I a homeowner doing all work officers have exercised their I LE]Plumbing.repairs or additions
right of exemption per MGL 12. Roof repairs
myself [No workers comp. n
insurance required.]t c. 152, §1(4),and we have no 1 M. Other
w� SGl d111.Q s('Vl�
.employees: [No workers'
��ow�comp. insurance required.] GWI..t?i
applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
neowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
ractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
iyees. If the sub-contractors have employees,they must providte their workers'comp.policy number.
an'employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
-mation. _
ance Company Name: �� j
y#or Self4ris.Lic.#: 0 0 W CL 930 I Wz 1 Expiration Date: ( W
site Add 9 �� � � �1� City/State/Zip: '4(ja �lLS
ress: _
:h a copy pf the workers' compensation policy.declaration page(showing the policy number and expiration_date).
re.to secure coverage as.required under Section 25A of MGL c. 152.can lead to the imposition of crimirial penalties of a
ip to V,500.00 and/or one-year imprisonment:, as well as civil penalties in the form of a STOP WORK ORDER and a fine
to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of -
ti ations of the DIA for-ffizur00592age verification.
iereby certi ins. enalties of perjury that the information provided above is true and correct.
tore: Date:
t-U,
ficial use only. Do not write in this area, to be completed by city or town offlciaL
ty or Town: Permit/License#
tong Authority,(circle one):
3oard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
3.ther
ntact Person: Phone#:
# 112/31/2008 14: 18 Bryden & Sullivan Insurance Donna Seviour4Margo 1/2
AC pRQ CERTIFICATE OF LIABILITY INSURANCE OP DATE /
SPRIN-1 12/31/08
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Bryden & Sullivan Ins Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
88 Falmouth Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Hyannis MA 02601
Phone: 508-775-6060 Fax: 508-790-1414 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A
Associated IDdusts:ies of MA
INSURER B:
SpTinkle Home Improvement Inc. INSURER.C:
199 Barnstable R INSURER D:
Hyannis MA 02601
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 RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEENREDUCED BY PAID CLAIMS.
I SR D - POLICYEFFEOTIVE POLICY EXPIRATION
LTR NSRD TYPE OF INSURANCE POLICY NUMBER DATE(MMIDDlYY DATE(MMA)D/YY) LIMITS
GENERAL LIABILITY EACH OCCURRENCE - $
COMMERCutL GENERAL LIABILITY • - PREMISES Ea occurence $
CLAIMS MADE a OCCUR MED EXP(Any one person) $
PERSONAL 8 AOV INJURY $
GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPUES PER: - PRODUCTS-COMP/OP AGO $
POLICY JECOT- LOC "
AUTOMOBILE LIABILITY
- COMBINED SINGLE LIMIT $
ANY AUTO (Ea accident)
ALL OAMED AUTOS -
BODILYINJURY -g
SCHEDULED AUTOS (Per person)
HIRED AUTOS -
- P' BODILY INJURY $
NON-OWNEDAUTOS - (Peracacient)
PROPERTY DAMAGE $
(Per accident) -
GARAGE LIABILITY - AUTO ONLY-EA ACCIDENT S
ANY AUTO - EAACC $
- OTHER THAN
AUTO ONLY. AGO S -
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ tj
OCCUR EI CAMS MADE _ t - AGGREGATE S
$
DEDUCTIBLE -
4
RETENTION $ •- g
WC STATU- OTH-
WORKERS COMPENSATION AND - TORYUMITS ER
EMPLOYERS'LIABILITY
A ANY PROPRIETOR/PARTNER/EXECUTNE AWC7004943012009 01/01/09 01/01/10 E.L.EACH ACCIDENT $ 500000 ,
OFFICER/MEMBEREXCLUDED7 E.L.DISEASE-Fh EMPLOYEE $ SOOOOO
d yes,describe under
SPECl4l PRO%ISIONS belbr E.L.DISEASE-POLICY UMIT - $ 500000
DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS -
CERTIFICATE HOLDER CANCELLATION
SPRNKHO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION '
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
Sprinkle Home Improvement, Inc NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
Fax #508-775-1350
Margo Mack IMPOSE NO OBLIGATIOROR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
199 Barnstable Rd. REPRESENTATIVES.
Hyannis MA 02601 AUTHORIZED REPRESENTATIVE
Kelle A.Sullivan
ACORD 25(2001/08) O ACORD CORPORATION 1988
t {t'o ii cl ql>l3uilding.Regulatitiiiy and St'iiidsrr<I:c
r " i .Construction Supervisor. ice.nS'c
p` Li!cense: G'S 6.643
r
• , ¢ T'0' 9427
Expi(riatron.: 10/8/2009
Rest'r fi.6n: 00.
BRAE)'K SPR.INKLi
190 LOTHRO:PS LANE i
W BARNSTAKE M'A 02668 c6lillniS.06461
,I
00 35;000 cf en'ctesed space' }
LA Masonry onty
' IG-1 ..2-F4rnily fIom`es =
t Failure:to possess a current ed1 4, of{f1i`e,
i �:
Nlassack'.usetts S"hate Buiidang Code
i Fs cause for revocation of this 1tceiS;e: i
ra
BoarB o'GBui➢ding d2qulations and Standards
i1� kv t- �ir HOME IMPROVEMENT CONTRACTOR
7
Registration: 103757
} 'r" Expiration: 7I9/2010 Tr## 2711033
Type:;>'PnVate Corpo.Fa#ion
SPRINKLE HOME lM`PR0 EMENT,.ING.
Bca'd Sprinkle
Hyannis MA 02601 Admi'n�stratoi:
License or registration valid for individul use ori➢y
before the expiration date. If found return to:
t Board of Building Regulations and Standards
One Ashburton Place Rm 1301
Boston,Ma.02108
F3'
Not valigit t sig ture
8. Fencing, carpentry,painting,plumbing, electrical, dry wells, etc., and all other work necessary that is
not contained in this contract, shall be the responsibility of the Homeowner.
RIGHTS TO CANCEL
The Owner may cancel this Agreement if it has been signed by the Owner at a place other than the
address of the Contractor, which may be his main office or branch thereof, provided that the Owner notifies the
Contractor in writing at his main office, or branch by ordinary mail posted, by telegram sent or by delivery,.not
later than midnight of the third business day following the signing of-this Agreement.
WARRANTIES
The Contractor warrants that the work furnished hereunder shall be free from defects in workmanship for a
period of two (2) years following completion and shall comply.with the requirements of this Agreement. In the
event any defect in workmanship, or damage caused by the Contractor, his subcontractors, employees or agents,
is discovered within two years after completion of any job, including cleanup, the Contractor shall,at his own
expense, forthwith remedy, repair, correct, replace, or cause to be remedied, repaired, or replaced such damage
or such defect in workmanship as long as the owner has paid their agreed contract in full.- The foregoing
warranties shall survive any inspection performed in connection with the agreed upon work.
All warranties for product supplied by the Contractor under this Agreement shall be those given by the
manufacturers of such product, which shall be and hereby passed directly to the Owner. Such manufacturer's
warranties, the Owner may be required to register or mail in a warranty card or other evidence of ownership,
and use of such product in order to activate such warranties. The Owner's failure to send in or register such
documentation, which failure voids that manufacturer's warranty, shall not create any responsibility for the
Contractor to warranty such product.
Note: Any changes in the contract during the duration of the project which results in additional monies
due will be paid in full to the contractor at the time of the change.
I authorize Sprinkle Home Improvement to act on my behalf in all matters relative to the work to.be
performed on this job (i.e.permits, applications etc.) if necessary.
0
H.A.0 bate Brad K. Sprink1b Date .
Celebrating 62 years in business!!
,. ;
z BLE
Town ofarii
Regulat �- F8tt$iM 9: 17
s�twsxesr.E Thomas F.Geiler,Director
16 Buildine Division
Tom Perry,Building Ca"Amier
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
I, Y)n U h[n , as Owner of the subject property
hereby authorize lcuy\ JA:M& TM0&)()6J-JLMt, to act on my behalf,
in all matters relative to work authorized by this building permit application for.
(Address of Job
Signature of Owner 'Date
J k c,r0 f) ID LI�J
Print Name
If Property Owner is applying for permit please complete.the +
Homeowners License Exemption Form on the reverse side.
Q:FO RMS:O WNERPERMISSION
THE Town of Barnstable
�pU Tp��
Regulatory Services iJ
Thomas F.Geiler,Director
• swrwsr BEZ,
M s9. A.•� Building Division
fED MA't
Tom Perry,Building Commissioner
200 Main.Street,_Hyannis.MA_02601._ _....
wpm.to w n.b arnsta bl e.ma.us
Office: 508-962-403 8 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION:
number street village
"HOMEOWNER":
name home phone# work phone#
CURRENT MAILING ADDRESS:
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and
to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as
supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she'resides or intends to reside,on which there is,or is intended to-
be,a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two-year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the building permit. (Section 109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes, bylaws,rules and regulations.
The undersigned"homeowner"certifies that_be/she understands the Town of Barnstable Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
Signature of Homeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the
State Building Code Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that "Any homeowner performing work for which a building permit is required shall be exempt from the provisions
of this section(Section 1 D9.1.1-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 assuring the responsibilities of a supervisor(see Appendix Q,
Rules&Regulations for Licensing Construction Supervisors,Section 2.15).This lack of awareness bften 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 fomi/certification for use in your community.
Q:forms:homeexempt