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HomeMy WebLinkAbout3990 MAIN STREET (:3?. fl2frW S 7L The to Town of Barnstable a ,:,.. g �1w11,;': � � "Y°�., �� ''�s.�- �'� ;#�;;� � � �'�. F+ � "t8 ry <�Lzx��.,�� � � .Y.� `K: �tw �� 3 Post-This:CardTSo":That it is V,sible:Fromythe Street �A : roved Plans Must be,Retained on,Job;;and;this Card Must be.,K,ept K .4 '� �• '. .H °B 'n`�IVlad �. � � PP �:� � � � �� � � � _ �� �� �' �'�� • i63P%bMø$" s ." . 44` i Whe"e aFCertificate of Occu anc *-,R,e'"uired�uc�h-Buildin 'shalhNotLbe$cu ieduntil a Final Inspection has4been made er t P Y .. . q .,,. g.. : .. . . .p . _ �,_ .-- ,a §,.w. .y. ._;teams- Permit No. B-19-682 Applicant Name: STEVEN KADY Approvals Date Issued: 03/19/2019 Current Use: Structure Permit Type: Building-Alteration INTERIOR Work Only- Expiration Date: 09/19/2019 Foundation: Residential Ma Lot 336-039 ZoningDistrict: RF-2 Sheathing: P Location: 3990 MAIN ST./RTE 6A(BARN.), BARNSTABLE fl :. Contractor.Name`.; ;STEVEN KADY Framing: 1 Owner on Record: DAVIS, PHYLLIS T TR Contractor;License 126014 2 Address: 3990 MAIN STREET ' ..-..m•.. -` Est Project Cost: $20,000.00 Chimney: CUMMAQUID, MA 02637 k Permit Fee: $ 152.00 Description: Remove and replace(2)Chimneys from roof line up ;r^ePa i y Insulation: Feid:;` $ 152.00 Final: Project Review Req: Date 3/19/2019 i Plumbing/Gas Rough Plumbing: Building Official This permit shall be deemed abandoned and invalid unless the work authonzed by this permit is commenced within six months after issuance. Final Plumbing: All work authorized by this permit shall conform to the approved application and the approved construction documents;'for which`this permit has been granted. All construction,alterations and changes of use of any building and structures,shall be in compliance with the local zoning by laws and codes. Rough Gas: This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for pablic inspection for the entire duration of the— Final Gas: work until the completion of the same. . The Certificate of Occupancy will not be issued until all applicable signatures by theBuildn gland Fire Officals are provided on this permit. Electrical Minimum of Five Call Inspections Required for All Construction Work:` t r -f k 't 1.Foundation or Footing Ai'_ 4 - N T�� Service: 2.Sheathing Inspection v� -1,,,,' ! = 3.All Fireplaces must be inspected at the throat level before firest flue.liningiis installlle�d. , , Rough: ':_ 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Rough: 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work shall not proceed until the Inspector has approved the various stages of construction. Health "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final: Building plans are to be available on site Fire Department All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: Y . . . . , it* "°�. �-1 �" l0 U oC • p� Application Number '5 .06 unee Permit Fee Other Fee s639. ♦q Total Fee Paid �a acl TOWN OF BARNSTABLE Permit Approval by.... on.. 4..l..'i.. BUILDING PERMIT 3Map ,�(p Parcel DM APPLICATION Section 1 — Owner's Information and Project Location - Project Address '�9'st$ {ttli6/ Village C'UA1 I/.aQviJ o Ol'itili,. Owners Name liiiiic ri) Co Owners Legal Address .��G Cwtr ST c I 0 213 City C 01ccti State Zip `.4 09 a � Owners Cell# j 3(t1,—. •J1 S.6 E-mail PTO G Gitr col. Gt/ w„ Fr; Section 2 —Use of Structure Use Group ❑ Commercial Structure over 35,000 cubic feet ❑ Commercial Structure under 35,000 cubic feet ❑ Single/Two Family Dwelling Section 3 —Type of Permit ❑ New Construction ❑ Move/Relocate ❑ Accessory Structure ❑ Change of use ❑ Demo/(entire structure) ❑ Finish Basement ❑ Family/Amnesty ❑ Fire Alarm Rebuild ❑ Deck Apartment © Sprinkler System ❑ Addition ❑ Retaining wall ❑ . Solar ❑ Renovation 0 Pool ❑ Insulation Other—Specify Section 4 - Work Description eelkoVE clitk Id-�'4CC---- 1 c4.Ail tvEy5 fi°`1 r 11'dt cJ e 1 I Last undated: 11/15/2018 Application Number Section 5—Detail i Cost of Proposed Construction ko,cad Square Footage of Project Age of Structure _ Dig Safe Number # Of Bedrooms Existing Total#Of Bedrooms (proposed) 110 MPH Wind Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist ❑ Design Section 6—Project Specifics ❑'Wiring ❑ Oil Tank Storage ❑ Smoke Detectors ❑`Plumbing ❑ Gas ❑ Fire Suppression ❑ Heating System ❑ Masonry Chimney El Add/relocate bedroom !l Water Supply i ❑ Public ❑ Private Sewage Disposal ❑ Municipal El On Site 3 l Historic District ❑ Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility: I am using a crane 0 Yes 0 No 1 Section 7- Flood Zone Flood Zone Designation Within or adjacent to a wetland, coastal bank? Yes ❑ No ❑ e Section 8—Zoning Information Zoning District Proposed Use Lot Area Sq.Ft. Total Frontage Percentage of Lot Coverage #of Dwelling Units (on site) 1 Setbacks Front Yard Required Proposed Rear Yard Required Proposed Side Yard Required Proposed Has this property had relief from the Zoning Board in the past? El Yes El No Last updatM• 11/15/2018 Application Number Section 9- Construction Supervisor Name SrLW kfr / Telephone Number `S? S6-5 7 Address (d1tj 3 City SI State ►ill" Zip Gg.S License Number QS 7$,y7 License Type Expiration Date I G'3-A Contractors Email SEVL G CE Gw,Ay-C Cell # sG$7 I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation re. No.y 780 C r. d the Town of Barnstable.Attach a copy of your license. Signature .r 7 Date Section 10-Home Improvement Contractor Name cTC 1d �(� S4quiaoit &OS.� Telephone Number Address1-13B ��3 City State At. Zip Q3 15-�f Registration Number I gd Expiration Date —71c I understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required e Town of Barnstable.Attach a copy of your H.I.C... Signature Date 3-51( Section 11 -Home Owners License Exemption Home Owners Name: Telephone Number Cell or Work Number eP I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT SI.GNATURE -Signature Date Print Name Si E icitt Telephone Number ���-36�7 E-mail permit to: @ STD k'9i ca C6r Last updated: 11/15/2018 . • Section 12 -Department Sign-Offs Health Department ❑ Zoning Board(if required) ❑ Historic District El Site Plan Review(if required) ❑ Fire Department ❑ Conservation ❑ For commercial work,please take your plans directly to the fire department for approval. Section 13— Owner's Authorization I, , as Owner of the subject property hereby authorize 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 Print Name • . Last updated: 11/15/2018 atm JICVCII nddy Ma. Licensed Construction Supervisor#059847 I-none: outs-obi-za to P.O Box 493 _. _. . . . .,... Toll free:800-567-9787 I oil I IVUtI I. IVIQ VLJ't i Cell: 508-566-5087 rax: bu -bbs-Lbib Email: Steve anSteveKadvMasonN com www.SteveKad Masonry com PROPOSAL • February 25,2019 Phyllis Davis dJJV IVIaI I Vt. Cummaquid, Ma. 508-362-3958 PT^`'fir„r,..d ��s i+=com+,"vc�peCod.l tf?..( WORK TO BE PERFORMED:Chimney 1 • Construct ground&roof staging • Remove center chimney down to roofline • Chatham.Panflash IPta-k,111011 W.t LlIiliiibUy o Using Boston Colonial brick, with detailed crown TOTAL: *Labor,Material,Disposal: $10,000,00 WORK TO BE PERFORMED:Chimney 2 ▪ Construct around&roof staoino • Remove center chimney down to roofline • Chatham Panflash • Re-construct chimney o Using Boston Colonial brick, with detailed crown TDTAI iPiiv7i➢VJ Villa ficvr�i„JAW;r WI,w'Via%MI UV WWI `v.,1�iiPfy wivi.s auatirr+,,e *Labor,Material,Disposal: $10,000.00 *Add stainless steel chimney caps,if wanted,ADO$400.00 EACH 75' 0% o Schedule balance due u on co ' let�on , ita 9-( s . ii i LC?"O® CERTIFICATE L ,---LIABILITY INSURANCE DATE(MM/DD/YYYY) 08/23/2018 — 1THIS 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(ies)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 endorsement(s). PRODUCER CONTACT NAME: Suzanne Harrington MURRAY&MACDONALD INSURANCE SERVICES INC PHONE ea ); (508)289-4170 FAX E-MAIL (A/C,No): ADDREss: sharrington©mmisi.com 550 MACARTHUR BLVD INSURER(S)AFFORDING COVERAGE NAIC# _ BOURNE MA 02532 INSURER A: TRAVELERS INDEMNITY CO OF AMERICA 25666 i INSURED INSURERS: KADY STEVEN DBA STEVEN KADY&SON MASONRY CONSTRUCTION INSURER C: INSURER D: P 0 BOX 493 INSURER E: FALMOUTH MA 025410493 INSURER F: COVERAGES CERTIFICATE NUMBER: 306834 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR INSD AND POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) UMITS COMMERCIAL GENERAL LIABIUTY EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES(Ea occurrence) $ MED EXP(Any one person) $ N/A PERSONAL$ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY JECT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABIUTY ' COMBINED SINGLE LIMIT $ (Ea accident) —ANY AUTO BODILY INJURY(Per person) $ ALL OWNED — SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) $ $ UMBRELLA UAB _ OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION S $ WORKERS COMPENSATION X STATUTE EORH AND EMPLOYERS'LIABILITY Y/N ANYPROPRIETOR/PARTNER EXECUTIVE E.L EACH ACCIDENT $ 500,000 A OFFICER/MEMBEREXCLUDED? NIA N/A N/A 6HUB931X732118 08/29/2018 08/29/2019 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below - N/A . DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,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.govIlwd/workers-compensation/investigations/. Sole proprietor has not elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town of Mashpee ACCORDANCE WITH THE POLICY PROVISIONS. 181 Great Neck Rd AUTHORIZED REPRESENTATIVE n,._,Q C Mashpee I MA 02649 Daniel M.Cr ey,CPCU,Vice 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 • , • didach „, , - ..evmaneaeakii c/g/ilauaelk I eirst•Cco,p,sumes:Attairs 46ss)rig.., flagufation FiOMEIM'PRONIEMBSICpNTRACTOR Registration-, ,pipiration 1:280T-4, 04/07/2020 • .71EVEN,ICADY .*, ••••,,, :- STEVENLAKADY s(;• ---- • • 10R_OC,KEEDG.,E,D13,,:'fi-, •a?' •;141Mlit1arel:-irklA'02568- Undersecretary • • Registration valid for individual use only before the exPiration date, .1f found return to: • Office of Consuiner Affairs and Business Regulation _ One:Ashburten Place-Suite 1301 Boston,MA 02108 Not 'ali hout signature _ Construction Supervisor Specialty Restricted to: CSSL-MA-Masonry • • Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. For information about this license Call(617)727-3200 or visit www.mass.gov/dpl - Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constructio0-,s-Ntf04,sq r Specialty CSS L-059847 :1,1; EjL„pires.:.,10/03/2020 •". STEVEN L KADY - PO BOX 493 0 ”Jf-"7. tj'T FALMOUTH MA:0294T •-• Ofssg40 •. - Commissioner • • The Commonwealth of Massachusetts x_,,,_ Department of Industrial Accidents !`' '' f Office of Investigations :!�! r 600 Washington Street �'1"� Boston,MA 02111 ,r, `'-_ =,' www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly I `f�0/O Name(Business/Organization/Individual): T��� ' �Y Address: . rd A V13 City/State/Zip: tg( tC 1i Phone#: 5 S 3 -kSi3 Are y an employer?Check the appropriate box: • Type of project(required): • 1. I am a employer with. 4. 0 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. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. Ei Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp.insurance comp.insurance.: required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3. officers have exercised their I am a homeowner doing all work11.0 Plumbing repairs or additions myself [No workers'comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.0 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 contactors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Akt�` 0f Policy#or Self-ins.Lic.#: (f f V6 l it l(T 3 I.I i g Expiration Date: X`Z 1 (9 Job Site Address: Yqa Vks%4/ `J` City/State/Zip: Cv QLiici 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 l ' for insurance coverage verification. I do hereby certify un � e p •' nalties of pedury that the information provided above is true and correct. Signature: Date: 3`S-11 Phone#: SS_ 81.5 . Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: _ Phone#: • Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. 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 oth ''legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representativ of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity, ploying employees. However the owner of a dwelling h= e having not more than three apartments and who resi.- therein,or the occupant of the dwelling house of anoth- who employs persons to do maintenance,constru 'en or repair work on such dwelling house or on the grounds or appurtenant thereto 01211 not because of such-,••ployment be deemed to be an employer." MGL chapter 152,§25C(6) o states that"every state or local licensin agency shall withhold the issuance or renewal of a license or pe it to operate a business or to construct s i dings in the commonwealth for any applicant who has not prod iced acceptable evidence of complian • ' the insurance coverage required." Additionally,MGL chapter 15 , §25C(7)states"Neither the commo ealth nor any of its political subdivisions chap enter into any contract for the p- ormance of public work until : -.table evidence of compliance with the insurance requirements of this chapter hay been presented to the contracting :uthority." Applicants Please fill out the workers' comp-• ation affidavit completely .y checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s) ,.• e(s),address(es)and one number(s)along with their certificate(s)of insurance. Limited Liability Comp:. (LLC)or Limited L.:•ility Partnerships(LLP)with no employees other than the members or partners,are not required • carry workers'co•,.•ensation insurance. If an LLC or LLP does have employees,a policy is required. Be ad d that this affi•: ' may be submitted to the Department of Industrial Accidents for confirmation of insurance • erage. Also +e sure to sign and date the affidavit. The affidavit should be returned to the city or town that the appli.:;on for th•permit or license is being requested,not the Department of Industrial Accidents. Should you have any qu..u ons - •i•g the law or if you are required to obtain a workers' compensation policy,please call the Departma•r<. the • •••ber listed below. Self-insured companies should enter their self-insurance license number on the appropriate •i e City or Town Officials Please be sure that the affidavit is complete and p -• egibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the r •ce o . •vestigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number •'ch '1 , used as a reference number. In addition,an applicant. that must submit multiple permit/license appli si ins in any giv-• ear,need only submit one affidavit indicating current policy information(if necessary)and under"Job►ite Address"the :•• -cant should write"all locations in (city or town)."A copy of the affidavit that has been o cially stamped or marke• •l the city or town may be provided to the applicant as proof that a valid affidavit is on fil for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is ob g 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 • 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 number. Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations • - 600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFB Fax#617-727-7749 Revised 4-24-07 www.r►um.gov/dia ` Town of Barnstable *Permit#,2 670 I 1 1-1 Expires 6 months from issue date (, 'c Regulatory Services Fee c Op b �\ Thomas F.Geiler,Director Building Division X-PRESS PERMIT Tom Perry,CBO, Building Commissioner 2007 200 Main Street,Hyannis,MA 02601 MAR 2 • www.town.barnstable.ma.us OF AR TABL Office: 508-862-4038 TOWN 'ax: 508-790-6230. EXPRESS PERMIT APPLICATION - RESIDENTIAL 0 Y L I Not Valid without Red X-Press Imprint �,l Map/parcel Number �.j(.D 639 3 P V Property Address _MO O 01 i9i) -S+ ' 2/Residential Value of Work 7,'7c o, 00 Minimum fee of$25.00 for work under$t$00.00 Owner's Name&Address T1\ /f L`S DU£s 7 y °1.I6 144;,,, 9 Cavii,siu /As I Contractor's Name tAVv'C4 l e.&r s (( Telephone Number• 5- b"8. 'O Home Improvement Contractor License#(if applicable) / 5 6/S� Construction Supervisor's License#(if applicable) ' %I%�C, ❑Workman's Compensation Insurance Check one: 0 I am a sole proprietor []/I am the Homeowner I have Worker's Co �mpensation Insurance p • Insurance Company Name I U Or u (edr_5 Workman's Comp.Policy# U 23 e °7 r L/4 y`..y C Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to 4.ir AA oc1 De S 6S64-/ 1 ❑Re-roof(not stripping. Going over existing layers of roof) !! ❑ Re-side ;> ❑ Replacement Windows/doors/sliders. U-Value (maximum.44) I *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 is required. SIGNATURE: l' t , , (V \/e Q:Forms:expmtrg Revise061306 i I � _ .✓' ci:114E l\ Town of Barnstable~O ass,, Re ulator Services BARNSTAg YMASs Thomas F.Geiler,Director rEp;p. A,� Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must • Complete and Sign This Section If Using A Builder I, f ' /J/ 5 T 4 L��j ,as Owner of the subject property hereby authorize /12' d 6 A pe 46, to act on my behalf, in all matters relative to work authorized by this building permit application for: 37 J /4 (Address of Job)J • j3 aqd7 na e of Owner ate • ill II ( AV/ s P t Name Aye/ S, 1)111/° S Q:FORMS:OWNERPERMISSION f • The Commonwealth of Massachusetts • Department of Industrial Accidents . _' Office of Investigations • set= • 600 Washington Street °I! • Boston,MA 02111 . • inr s www.mass.gov/dia • Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): i c.G4 CC °� C�(.....e--t • #Address: ;-S o PU' � 1 _. ' City/State/Zip: 10 Y-6.1r-- Phone.#: 3 -S s5--( '6 • Are you an employer?Check the appropriate box: • Type of project(required):. 1.❑ I am a employer with 4. 0 I am a general contractor and I 6 New construction • e loyees(full and/or.part-time).* have hired the sub-contractors • a'sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. 0 Demolition . h andave workers' working for me in any capacity. employees9. 0 Building addition • [No workers'comp.insurance comp.insurance. required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their . 11.0 Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152,§1(4),and we have no 13.0Other employees. [No workers' comp.insurance required.] • *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that 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. p Insurance Company Name: +c1+-u 1 Q- 5 Policy#or Self-ins.Lic.#: b g „al 'S / A'/ 2 —�• v 6, Expiration Date: 3 -.z- (7— ( Job Site Address: 5??6,. 4,k( S " City/State/Zip: Co v.. v 0 0:L1MA--. Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. S nature:V , ,, Date: 3 d1 y.,7 • Phone#: F ? g 0 ( Official use only. Do not write in this area, to be completed by city or town official City or Town: - Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: • . Phone#: • • Information and Instructions . . Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. 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 Te eiver_or_.i=us_tee'of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartm,•is and who resides therein,or the occupant of the dwelling house of another who`employs persons to do mainte+ance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not la:cause of such employment be deemed to be an employer." • MGL chapter 152, §25C(6)also stat that"every state or ocal licensing agency shall withhold the issuance or renewal of a license or permit to ope to a business or ,I construct buildings in the commonwealth for any • applicant who has not produced accep ble evidence o`compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)s des"Neither 71 a commonwealth nor any of its political subdivisions shall ' insurance anycontract for.theperformance o ublic wo�� unto acc table evidence of compliance with the in.,ura_ce enter into until-acceptable n4 requirements of this chapter have been presentdto the ontracting. authority." q Applicants • • Please fill out the workers' compensation affidavit co 53•letely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s), address(-s) :nd phone number(s) along with their certificate(s)of insurance. Limited Liability Companies(LLC)or L'to.ted' iability Partnerships(LLP)with no employees other than the members or partners, are not required to carry worke is'comp . ation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this .ffidavit ' be submitted to the Department of Industrial • Accidents for confirmation of insurance coverage. so be sure sign and date the affidavit. The affidavit should be returned to the city or town that the application fo the permit or h•-nse is being requested,not the Department of Industrial Accidents. Should you have any questio. regarding the law if you are required to obtain a workers' . compensation policy,please call the Department at t i e number listed belo; Self-insured companies should enter their self-insurance license number on the appropriatelin-'. City or Town Officials f • Please be sure that the affidavit is complete and prin ed legibly. The Department ha- 'rovided a space at the bottom of the affidavit for you to fill out in the event the 0 ,!a of Investigations has to contac,you regarding the applicant. • Please be sure to fill in the permit/license number whih will be used as a reference num.er. 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"• •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 ust be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business o commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidait. The Office of Investigations would like to thank you in advance for your cooperation and should youNhave any questions, - please do not hesitate to give us a call. The Department's address,telephone-and fax number: The Commonwealth of Massachusetts • Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel. #617-727-4900 ext 406 or 1-$77-MASSAFE Fax##617-727-7749 Revised 11-22-06 www.mass.gov/dia I j • • " -� l 1+ (` BOARD OF BUILDING REGULATIONS 4 A. License: CONSTRUCTION SUPERVISOR I,y ,,- , 4. 054428 i s Number CS i lit is Birthdate,05121J71 958 lI i c Tr.no• 25180 i. ;,,,, Expires 05/21120.08 e Restnted ©1 - K . BARRY B ERRILL ; i /, j 31 ETT RiT 0— ,,/9 I ,:".1 , CENTERVILLE, MA 02E32- Commissioner glie.� 04tWea h 0/4-1 d lA 1 \ Board of Building Regulations and Standards Br. O,VEMENT CONTRACTOR —`-e_ HOME IMF 6= i_ " Registration. 108615 . -1_-_ ___= 20/2008 ' yp (4idual; BARRY MERRILta Rim - Barry Merrill - 312 Skunknet Road Deputy Administrator Centerville,MA 02632 MID CAPE ROOFING 11 RUSSO ROAD WEST YARMOUTH,MA 02673 508-775-3799/508-385-8801 Barry Merrill Paul Merrill Job Site Address Mailing Address Name Ut 111;5 0,`s Name Street 3 Street City C6 M0.401 City Telephone. Telephone We hereby propose to furnish all the materials and all the labor necessary for the completion of: roof replacement of the dwelling at the above address. Mid Cape Roofmg proposes to remove and dispose of the existing roof. The roof will be replaced with 30 year Certainteed Woodscape Shingles. CIF c,Joo� Aluminum drip edge will be installed along the gutter line. Ice&Water shield will be installed on bottom edges to protect ice back up. 15 pound felt paper will also be applied. The shingles will be installed using 11/4 inch roofing nails. New vent collars will be installed. Ridge vent will be installed along the ridgeline of the roof to provide proper venting of the attic space. Certainteed warrantees the materials for a period of 30 years. Mid Cape Roofing guarantees the workmanship for a period of 10 years. All walls and landscaping will be protected from damage;the property will be raked and cleaned of all debris. All material is guaranteed to be as specified and the above work is to be performed in accordance with specifications submitted for above work and completed in a substantial workmanlike manner for the sum of: $ 1 .00-All discounts have been applied. Payment made as follows: Deposit of: $ 96®a.00 and remainder to be paid on completion. 2' pbS Y</69-1 Any alteration or deviation from the above specifications involving extra costs will become an additional charge over and above the estimate and will be discussed with the homeowner. Respectively Submitted by Mid Cape Roofing NOTE: This proposal may be withdrawn by Mid Cape Roofing in not accepted within 30 days. Acceptance of Proposal The above prices, specifications and conditions are satisfactory and are hereby accepted. Mid Cape Roofmg is hereby authorized to perform work as specified with payments made as outlined above. j 41j O `�/2-Accepte� 0 1