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HomeMy WebLinkAbout0645 STRAWBERRY HILL ROAD s�i h,'�'^''�4. �„h} y�F ,�-� �,�..�,' v � tip��-.�' Y k.� +,� ,., .. :.x�.r '• �iY,.�� x w„. .."- :.,9.� .—�.: -�� „. ,,,;,..,._ _ .n: t �' ��v t �.t.? ������ �rv�` 4�:`K �:SYS�fi ;�t... . , dot .. :_:. � ., .,.. � ." � � '� rfi }, a i' . � fi� e y 3r � fi s�� 5'Sx `+��� � �t{c'��� {�i �, `X� N� v r �k�. a v,, � 4 k tE v T't:.< �+ y � � ;n'�`eS`t c.fJ � �' '` �i�� � 4 a �;.., .. � t,, ��f+Fy � y. � � k �,,,1�:q �.� ,�v �:a��qC s,�,y t �� ��°e��'r'SF � v.`�j S ,P; d . y4> ''��f 9� ,�y t a t�S+'�`�.r�p ��3^`,�L�,'� ..,yt���:,.'ti f,� v� `'pg.. a. a nr�`��� r 4 r 1 ,fi.:R tr. i�'4 „. �i } �^_ w� c _ c. n .v�. , - ,. _. .. ..i .. _ � t , a � ._ , ., �fi r .,: .� � � -., � �. � �,. .�.. .,, ' � � ''' .a i, � .�, � :;. � � r i � .� �.a. .. a �� "� .,� _• � �. ,. ;: - � ' ,� , ,, , , .. . , �( .: � .. ' � .. .. q. .. :.: � �. .., ;.. _ t ..' . - :. 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' .� .. :':r r _.. - - " t Town of Barnstable *Permit# �OF� rotyti Expires 6 months from issue date Regulatory Services Fee C72, 6 0 IARNSTABI.E, i y� l SS. �e Thomas F.Geiler,Director plfD MA't a Building Division , Tom Perry,CBO, Building Commissioner.® F� 200 Main Street,Hyannis,MA 02601y www.town.barnstable.ma.us ��� MAY 1F"ax2y00i-790-6230 Office: 508-862-4038 EXPRESS PERMIT APPLICATION - RESIDE° - �v syjRNSTA Not Valid without Red X-Press Imprint BLE Map/parcel Number Pro e Address "�� C�.Iaw P i Residential Value of Work 33, 0 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address V /G'k 1/' / 5-oe -17f !` / Contractor's Name W w�� n 2�1 Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) orkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I the Homeowner have Worker's Compensation Insurance Insurance Company Name a-o la -CS Workman's Comp.Policy# Q'7 3 / Copy of Insurance Compliance Certificate must accompany each permit. 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) Re-side �i #of doors replacement Windows/doors/sliders.U-Value r 36 (maximum .44)#of windows 1-5 *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 required..`, SIGNATURE: Y r O:\WPFILES\FORMS\building oermit forms EXPRESS.doc The Commonwealth of Massachusetts — Department of Industrial Accidents rt Office of Investigations j 600 Wasliington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: ]Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legiblv Name (Business/Organization/Individual): Y02_z r rrd-lm 02 ��G► Address: Es— City/State/zip: (��/dfC�V`` �' "� Phone#: 5-0 e Are yo employer? Check the appropriate box: Type of project(required): 1. I am a employer with 01�� 4. ❑ I am a general contractor and I 6 New construction employees(full and/or part-time),* have hued the sub-contractors listed on the attached sheet. 7. ❑Remodeling 2.El I am a sole proprietor or partner- 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. it 10.❑ Electrical repairs or additions ration and s required.] 5. We are a corporation � 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions right of exemption per MOL 12. .__ R f.re airs - Ysclf,.[No_yvorkels._coznP ❑- P insurance required.] c. 152, 1 4 , and we have no 13. Other / t § ( ) OTC! - employees. [No workers' comp. insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. T Insurance Company Name: / f a if .Policy#or Self-ins. Lic.#: q 73 I W 4Vl 01 Expiration Date: �7-11 dO Job Site Address: � �dW k°r' � ` 6 - 4ity/State/Zip:�r✓'f��/6 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 MOL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that he information provided above is true and correct. signature: ""`"L� "P Date: Phone# Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1 Board of Health 2. Building Department 3: City/Torun Clerk 4.Electrical Inspector 5. Plumbing Inspector 6. Other i� Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Piusuant to this statute,an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership,association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair.work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s)name(s),address(es)and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships (LLP)with no employees other than the members or partners,are not regiured to carry workers compensation insurance.- If anZLC or'LLl'does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' c m ensation policy, lease call the Department at the number listed below. Self-insured companies should enter their o P P Y�P P self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Accidents Department of Industrial A ents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 4-24-07 www.mass.gov/dia OF,VE Tp� 'Town of Barnstable Regulatory Services i y t BARNSI'ABLE& " Thomas F. Geiler,Director y, MAss. p);q..,a Building Division Tom Perry,Building Commissioner . 200 Main Street,Hyannis,MA 02601 ntiyw.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using ABuilder I / ,k ��li�'l Ga2 ,as Owner of the subject property /J hereby authorize �►�DC I 1 to act on my behalf, in all matters relative to work authorized bythis building permit application for: � li�id� U6l�� (Addiress of Jo ) Signature of Owner Date l Cal (h.J1C.� Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORMS:OWNERPERMISSION r r o Town of Barnstable o Regulatory Services " Thomas F. Geiler,Director • BnaxsrABLE, " tans. erg, 1639. ,�� Building Division pTfD '�A Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 mvw.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 t! CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to"include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned "homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORM S\homeex empt.DOC f CER`fIFICAT'E,OF LIABILITY INSURANCE r ATE(MMIDD►Y M 05/09/2016 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 policy(fes)must be endorsed. if SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement, A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements). PRODUCER CONTACT NAME: Anna Sanzo HUB INTERNATIONAL NEW ENGLAND LLC PHONE 508 945-7863 rac Nei: E AIL ADDRESS: anne.sanzo(@Iiubinternational.com 265 ORLEANS RD. INSURERS AFFORDINGCOVERAGE NAIC0 NORTH CHATHAM MA 02650 INSURER A: TRAVELERS PROPERTY CAS CO OF AM 25674 INSUREO INSURER 8 WENZEL FRAMING INC INSURERC: INSURER D: 45 WHIDAH WAY INSURER E: CENTERVILLE MA 02632 1 INSURERF: COVERAGES CERTIFICATE NUMBER: 51133 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 INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL 0 BR POLICY EFF POLICY EXP L R TYPE OF INSURANCE POLiCYNUMBER M_ MMfDDffm LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGETOR5NTED ' -PREMISES Eaoccurrence) $ MEDEXP(Anyoneperson) $ NIA PERSONAL 8 ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑PRO- LOC PRODUCTS-COMPIOP AGO $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ a accid nt ANYAUTO BODILY INJURY(Per person) S ALL OWNED SCHEDULED NIA AUTOS AUTOS BODILY INJURY(Per accfdent) $ HIREDAUTOS AUTOS NED PROPERTYDAMAGE AUTOS Per a nl $ S UMBRELLALIAB HocCUg EACH OCCURRENCE $ EXCESS LiAO CLAIMS-MADE NiA AGGREGATE $ DEO RETENTION $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YiN X PET UTE OR OFFIERPSRX CLo7EcuTly£ E'L:EACH ACCfOENT $ 100,000A oFFiCEMEUDE A NIA NIA 7PJUB0731N44915 07/11/2016 07/11/2016 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If)'es,describe under DESCRIPTION OF OPERATIONS bei. E.L.DISEASE•POLICY LIMIT I$ 500,000 N/A DESCRIPTION OF OPERATION$I LOCATIONS I VEHICLES (ACORD I(H.Additional Remarks schedule,may be attached If more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of Insurance shows the policy In force on the date that this certificate was Issued(unless the expiration date on the above policy precedes the Issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.govAwd/workers-compensationfinvestigatfons/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. 367 Main Street AUTHORIZED REPRESENTATIVE r3 Barnstable MA 02601 Daniel`M.Cro vWey,CPCU,Mce President—Residual Market--WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Massachusetts Depaitment;of Public Safety Board`of Building Regulators and Standards License CS-069055 Con struction.Supervisor J ' MARK A;W t ENZEL 'GENTERVILLE MA'02632 y � b _ missionec Expiration:;:` 06l17/20.18' e Cr,a�izn2cncacccll�t�'C ?aasac�u�e«€ � Office of consumer Affairs.&;Business Regulation HOMEIMPROVEMENTCONTRACTOR Registration100285. Type: Expiration 6�I15X201'8: PPivate Corporafion WENZEL FRAMINGf.&&A iz v 4 : x Mark Wenzel 45 V1(hitlah Way. P_;� ,-- .�F Centerville;MA:02632 Under secretary vv _ �'�✓L Parcel Detail Page 1 of 3 a iN ` - s, c � .. Lam"6/L/"'✓f✓" "� Ye: Y" ..- i♦ 1Aii1.�,. `,r`d� ��9 A � aye ,_. �. �� -, �. 1+/ ���v`�!✓U' � � � - Logged In As: Parcel Detail Friday,May 13 2016 Debi Barrows Parcel Lookup Parcel Info Parcel ID 1249-058 � �� I Developer Lot LOTS UN&D1 Location 645 STRAWBERRY HILII Pri Frontage 186 Sec Road WEST MAIN STREET I sec Frontage 292 I' __ _ Village CENTERVILLE I Fire District iC-O-MM Town sewer exists at this address NO _ ) Road Index 1546 Interactive Map y� v. , Owner Info owner BROWN, DONALD R TR) co- %MARCHANT, DENNIS� owner No PO BOX 442 streetz I city E ( state I zip02630 I country BARNSTABL I 1W Land Info ............................ ......... ......... ......... ......... ......... ......................................._.. ......... _ W,< ,. «..,,�..r..,,,, .«,«,<.,« ,«,�,�,� Acres 0.75 use ISingle Fam MDL-01 .I zoning RD-1 Nghbd 10105 Topography Level — I Road Paved I utilities Public Water,Gas Septic) „ Location Construction Info Building 1 of 1 Year 1950 .n Roof Gable/Hip ExtWood Shin le Built SRO _ Wall g Lavin . :.,,..,... Roof ..<«,.,..:..<,. ,,. .< ,,.�,�.«.,.. AC Area F1544 I cover€Asph/F GIs/CmpJ Type,None r Style Cape— Wall Rooms Cod Drywall Bed 4 Bedrooms . Model Residential FI or Carpet Rooms '1 Full 1NHalf— Grade Average I Type Hot Water Rota �7 R s Stories 1 1/2 Stories Heat OII Found- Fuel I ation z Gross 2988 Area Permit History Issue Date Purpose Permit# Amount lnsp Date Comments Visit History Date Who Purpose 5/5/2014 12:00:00 AM Tony Podlesney Change of Address http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=18041 5/13/2016 Parcel Detail Page 2 of 3 3/28/2014 12:00:00 AM Jeff Rudziak In Office Review 1/10/2001 12:09..00 AM Paul Talbot Meas/Listed-Interior Access 12/15/1990.12:00:00 AM ML Meas/Listed-Interior Access Sales History Line Sale Date Owner Book/Page Sale Price 1 11/23/2015 BROWN, DONALD R TR 29291/38 $1 2 8/29/2014 MARCHANT, VICKI R TR 28353/230 $0 3 1/15/1996 PEASE, ESTHER I TR 10031/194 . $1 4 10/26/1955 PEASE, GERALD E & ESTHER I 923/485 $0 5 4/14/2016 MARCHANT, DENNIS &VICKI R 29579/114 1 $2,50,000 Assessment History Save Year Building XE Value OB Value Total Parcel # Value Land Value Value 1 2016 $103,400 $21,000 $1,900 $118,800 $245,100 2 2015 $115,000 $21,300 $2,400 $120,900 $259,600 r 3 2014 $106,400 $21,300 $2,500 $120,900 $251,100 4 2013 $106,400 $21,300 $2,500 $120,900 $251,100 5 2012 $108,700 $21,100 $2,000 $120,900 $252,700 6 2011 $130,400 $3,300 $1,300 $120,900 $255,900 7 2010 $130,000 $3,300 $1,300 $120,900 $255,500 8 2009 $130,000 $2,400 $600 $171,800 $304,800 9 2008 $135,000 $2,400 $600 $184,000 $322,000 11 2007 $159,800 $2,400 $600 $184,000 $346,800 12 2006 $134,500 $2,400 $700 $201,000 $338,600 13 2005 $120,900 $2,300 $700 $160,800 $284,700 14 2004 $96,200 $2,300 $700 $136,700 $235,900 .15 200.3 $85,900 $2,300 $700 $51,600 $140,500 16 2002 $85,900 • $2,300 $700 $51,600 $140,500 17 2001 $85,900 i $2,500 $700 $51,600 $140,700 I 18 2000 $69,600 $2,500 $0 $34,300 $106,400 19 1999 $69,600 $2,500 $0 $34,300 $106,400 20 1998 $69,600 $2,500 $0 $34,300 $106,400 21 1997 $63,400 $0 $0 $34,300 $97,700 22 1996 $63,400 $0 $0 $34,300 $97,700 23 1995 $63,400 $0 $0 $34,300 $97,700 24 1994 $64,600 $0 $0 . $38,600 $103;200 25 1993, $64,600 $0 $0 $38,600 $103,200 26 1992 $73,400 $0 $0 $42,800 $116,200 , . 27 1991 $83,100 $0 $0 $60,000 $143,100 28 1990 $83,100 $0 $0 $60,000 $143,100 29 1989 $83,100 $0 $0 $60,000 $143,100 30 1988 $52,300 $0 $0 $29,700 $82,000 31 1987 $52,300 $0 $0 $29,700 $82,000 http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=18041 5/13/2016 ofIKET Town ®f Barnstable 'Perm it�0�0��- �%v Expires 6 monllis from issue(10 RNMerE Regulatory �'e't'�><ces rRA — ec �o f i5 ,�$ Thomas F. Geilcr, Director . 3 �INDI �pleon��n wilding Division -PRESS PERMffm Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 AUG 3 1 2009 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 TOWN OF BARNSTA9L EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number ;q� D SS Property Address e N:S— Srt H be�v t-�i f-✓; /f r� C''�'i'7 [Residential Value of Work Z2.3 i Minimum fee of$25.00 for work under$6000.00 Owner's Name &Address 6!�.esC. t 9 eg D r., e-to 1PE5 -?' Contractor's Name cap._ t' Telephone Number s-i1' -a 3 S Home Improvement Contractor License# (if applicable)_ 10142 Construction Supervisor's License#(if applicable) �j✓� — ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor I am the Homeowner 5?1 have Worker's Compensation Insurance Insurance Company Name7uy vg;I Workman's Comp. Policy# :2Z-0 929'/e. yata6Ci Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) tom) L[rRe-roof(stripping old shingles) All construction debris will be taken to etc % j C ❑ Re-roof(not stripping.' Going over existing layers of root`) ❑ Re-side ❑ Replacement Windows. U-Value (maximum .44) *Where.required: issuance of this permit does not exempt compliance with other town department regulations,i.e. 1-Iistoric,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Ro rovement Contractors License& Construct Supervisors License is required SIGNATURE,. 3 ��� '�f1�'�?--� 0:\WPFII-ES\FORN,fS\Erriress\ XPRESSPERM(T.DOC " The C'otntnonivealth of Massachusetts Department of Industrial Accidents Office of Investigations + d 600 Washington Street Boston, MA 02111 :Y•` ww)v.mass.gov/dia Workers' Compensation Insurance Affidavit: )Builders/Contractors/Ele'etricians/Plumbers Applicant Information Please Print Legibly Nanne (Business/Organization/Individual): 616 nr 7 Address: 1-r,'[ LicJF.fff� P City/State/Zip: Phone.#: �� Are you an employer? Check the appropriate box: Type of project(required): am a employer with 4. I am a general contractor and I ❑ .� have hired the stab-contractors 6. New construction employees(full and/or part-timel. Remodelin 2.0 I am a sole proprietor or partfter-' listed on the attached sheet. 7• Q. g ship and have no employees These sub-contractors have g• 0 Demolition working for me in any capacity. employees and Have workers' 9 Building addition [No workers' comp. insurance comp. uisurance.f � required.] 5. We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I 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 12 Ee Koof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp. insurance required.] *Any applicant.that checks box 41 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. xContractors 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 utstirance for my employees. Below is the policy andjob site information. Insurance Company Name: RXd!1e. p9B!'too/ L'a17 cnc o P7 e e_, Policy#or Self-ins. Lic.#: �7.0,0 ad aao 7 Expiration Date: Job Site Address: /o 4,5- S'V r.4t--o bee- 'Y %�o+�f�c� City/State/Zip: agew _- fir �il�at 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 imprison--nent, 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 Investigations of the DIA forof this statement maybe forwarded to the"Office of insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the inforination provided above is true and correct Signature RWe_Y Date: Phone #• -ro f L 3 VJ? " 3 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 S. Plumbing Inspector 6. Other r , is Information and instructions Massachusetts General Laws chapter 1S2 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in.the service of another under any contract of hire, express or implied, oral or written." An employer is defined as ,an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house of on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §2SC(6) also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." `Neither the commonwealth nor any of its political subdivisions shall Additionally,MGL chapter 152, §25C(7) states . enter into any contract for,the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if sub-contractors name(s), addresses)and.phone number(s) along with their certificate(s) of necessary,supply ( ) insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers'compensation insurance. If an LLC or LLP does have ? employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete"and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which.will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address" (be.applicant should write"all locations in__(city or town).".A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOTrequired to complete this affidavit. ncP Fr g� ons would h to thank you in advance for your cooperation and should you have any questions, o, �nve ti ti .� like P please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of ladustri,al Accidents Office of I.avestigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-72777749 Revised 11-22-06 www.mass.gov/dia I i �TREro ti Town of Barnstable Regulatory Services Thomas F. Geiler,Director Building Division 0 Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 'v4vw .town_barnstable.ma.us Office: 508-862-4038 Fax: S08-790- Property Owner Must Complete and Sign This Section If Using A Builder &'C2 as as Owner of the subject property hereby authorize )916e y�`i' (�� yq g e to act oa my behalf, in all matters relative to'work authorized by this build rtg permit application for. (Address of rob Signature of Owner Date Print Name If Property Owner is applying for permit please complete the Homeowners _License Exemption Form ion the reverse.side.' Town of Barnstable o Regulatory Services r Thomas F. Geiler,Director t s.taxsrAar.�. Building Division prFO � Tom Perry,Building Commissioner o - 200 Mairi-Street Hya�is;1vFA 02601 Tww.town.barnstable_ma.us Office: 509-862-4038 Fax: S08-790-6230 G HOMEOWNER LICENSE EXEMTTTON Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone tF work phone# CURRENT MAFLQ4G ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include oNcner-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. DEF]NMON OF HOMEOWNER persons)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than.one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 104.1.1) 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 Barpstable,Builftg Department rr,u= m inspection procedures and requirements and that he/she will comply with said procedures and requirements. SignaErm of Homr-av—Tcr 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 EXEMTTION The Code states that: "Any homeowner performing work for which a building pa niit is rcqui-d shall be exempt from the provisions of this section(Sccticn.109.1.1 -bcmising of construction Supervisors);provided that if the homeowner rngagcs a persons)for hire to do such work, that such Homc:)wncr shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibl7itics of a supervisor(see Appendix Q. Rulcs&Regulations fx Licensing Section ing Construction Supervisors,Stion 2.15) This lack of awarmcss oficn results in serious problcrns,particularly when the homcowncr hires unliccuscd persons In this cast,our Board cannot proceed against the unliccnscd�crson'as it would with a iiccnscd Supervisor. The homcowncr acting as supervisor is ultimately responsiblc. To ensure that the homeowner is fully aware of his/her respormbilitics,many communities require,as part of the pcn-n application, that the homeowner certify that htJshc undcrsfands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several tolvns. You mey care t amend and adopt sucb a fomn/ccrtification.for use in your community. , '8 / 2 //2009 8 : 38 : 25 AM 8988 (2 02/02 rf r ,' 'x`, ', 4•r' `� ,�: , 11'i, ' \..v^ 1pt't'c s' stFkr 'tir A0812712009 ISSUED TE d! �i�ld tti t.3t��•..,,:, >.'S.. I... .,..�i,}..>,.{-`r.er,'�4+?'7 t.t,M1 . x.ss>''r. I c� l R x4{. I,Vt ij?r�,fy<t{ i f 5 f'n i .,Salt RODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND 'eny Insurancz Agency Inc CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE 0 Box 1945 DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. N.Eastham,MA 026 51- CONVANIES AFFORDING COVERAGE INSURED Albert C Pease dba Albert C Pease III Builder COMPANY A A.I.M.Mutual Insurance Co LETTER 5 East Hill Road ellfleet,MA 02667-0000 - 1 ariri 1 .it s t,}t_}' :rs.. to ..*,�{ u'..t et is k.t� 37t zct 4s ts5,r G4 Y f 5 � [�k.7 si✓t' �t;'x'i5 4 1. Yt r, ✓•t:,,r•s?�';•s�'+..t s�'�,..}l r t1„�e> ,�`w� r' �Prv. �'tk:i. ylt ryf.{y..ta5? a �f'i4'•ii+:; Ei,j �a,�trJ�''tn':.:1..f.tr,-l�j. '�.��r}� f:-<�nixti?�c, 47,43.�°4� I,�,f,..R„�P_ �r4?�$ri.n,'>' 't,l�y�' s"?'.'�.&�;4..1.1�17��v ,1 ,.;a�:,Aef: THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INSURANCE POLICY NUMBER POLICYEFFECTIVE POLICY EXPIRATION - LIMITS LTR DATE(MMIDD/YY) DATE.(M.MIDDIYY) GENERAL LIABILITY GENERAL AGGREGATE- $ - - PRODUCTS-COMPIOP AGG. =COMMERCIAL GENERAL LIABILITY _ - ... PERSONAL&'ADV.INJURY II CLAIMS MADE=OCCUR - EACH OCCURRENCE OWNER'S 8:CONTRACTOR'S PROT. - - FIRE DAMAGE(Anyone tire) _ - MED.EXPENS E(Anyone person) AUTOMOBILE LIABILITY - COMBINED SINGLE - • 3 LIMIT - -- HANYALITO - BODILY INJURY - ALLOWNEDAUTOS - (Per person) 3 SCHEDULED AUTOS HIRED AUTOS BODILY e NON-OWNED AUTOS - - - - (Per ent)INJ " (Per acident) GARAGE LIABILITY Z PROPERTY DAMAGE- EXCESS LIABILITY - - EACH OCCURRENCE _ UMBRELLA FORM AGGREGATE OTHER THAN UMBRELLA FORM y4�j,l iJ`,,,,�i11��1.r Y{�!,�.rl },< ,,1 Hie V'1l`tmg,-; \y m WORKERS COMPENSATION AND STAT LIMITS STATE OTHER EMPLOYERS LIABILITY - - - MA- HEPROPRIETOR! EL EACH ACCIDENT S- 100,000 A PARNERSIEXECUTIVE - FFIc1ERSARE - 7008071012009 05/16/2009 05/16/2010 INCL ®EXCL EL DISEASE--POLICY LIMIT 500,000 EL DISEASE--EACH 1�0 000 EMPLOYEE COMMENTS/DESCRIPTION OF OPERATIONS OR LOCATIONS: ALBERT C PEASE IS NOT COVERED BY THE WORKERS'COMPENSATION POLICY. 0t'4}fir rWL Yi�M1:I Ii��')I} Hy Slll, j}y.k- 1;t_.L+ a „w,. tfr,.� SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE TOWN O F BA RN S T A B LE HEREOF,THE ISSUING COMPANY"WILL ENDEAVOR TO MAIL 15 WRITTEN NOTICE TO THE CERTIFICATE OLDER NAMED TO THE LEFT,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION UILDING DIVISION OR LIABILITY OF ANY KIND UPON THE COIAPANY,ITS AGENTS OR REPRESENTATIVES. T'TN:T..-PERRY 00 MAIN STREET / l/I�ti YANNIS,MA.U2601 - UTHORIZEDREPRESENTATIVE 8799 t;tf� .oR i i ati�sa a ar s � License or'registration valid fortndmdul use only HOME IMPROVEMENT CONTRACTOR before the expiration date.: It found return to: j Board of Building Regulations and Standards i Registration 101471 One Ashburton Place Rm 1301 - Expiration .,6/26/2010 Tr# 277172 Boston. Ma.02108 Type Individual ALBERT C. PEASE Albert Pease 95 East Hill Rd Wellfleet,MA 02667 f '.f/ Administrator j Not valid without signature Massachusetts- Department of Public Board of Building Reg gulations and Standards' Construction.Supervisor License License:_ CS 36407 Restricted to: _00 :ALBERT C PEASE 95 EAST HILL RDY4 WELLFLEET, MA 02667 c Expiration: 5/13/2010 0 muuissi"ner- Tr#: 5664