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TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
TO W N OF RINI T4i t- Application
Map q Parcell
Health Division (? '= p r Date Issued t C�
-t •
Conservation Division Application (J
Planning Dept. — =- Permit Fee q0
DI Eft
Date Definitive Plan Approved by Planning Board
Historic - OKH — Preservation/Hyannis
Project Street Address Lei x� lsLJe4 build,'h a--
Village ���
Owner �l�'f aJ s� r t' / r� Address --R® t�C L� �t i !\ I-4 %'o-s 0
Telephone &117 Aomasy v S v6 w 7?s-- 7,3 0 3. //1 a
,r
Permit Request S4 I f i t� �
/ �. I ve
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation°e Construction Type O9n
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units)
Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No
Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other
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 Authorization ❑ Appeal # Recorded ❑
Commercial ❑Yes ❑ No If yes, site plan review#
"Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name d wC tr,/45 E:71111 6�11helephone Number
Address �of �� ���� i �d.� r`� ✓' License # CS 0211{0 2-
'q Home Improvement Contractor# J®0(V6q
Worker's Compensation # [ l®;�102® 0
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE �I� DATE D �'
FOR OFFICIAL USE ONLY
N^
- 1
APPLICATION#
DATE ISSUED
` MAP/PARCEL NO.
'ryri
1
c ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION
t FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL -
GAS: ROUGH FINAL
6
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO. L
The Commonwealth of Massachusetts
Department of Industrial Accidents
' Office of Investigations
' 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Ledbly
Name(Business/Organizatioii/Individual): e1abbu�T=c / A }15d'� t_ STY(' �1,,�
Address: p y)a Ray l4Rnlq
City/State/Zip: w/- Phone#: / 8 g
Are you an employer?Check the appropriate box: Type of project(required):
L DQ I am a employer with 10 4. ❑ I am a general contractor and I
employees(full and/or part-time).*
have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g. Demolition
working for me in any capacity. employees and have workers'
9. ❑ Building addition
[No workers' comp, insurance comp.insurance.T
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself.[No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.] _r 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 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.
Insurance Company Name: U r
o ,
Policy#or Self-ins.Lic.#: " 10 A P 700 Expiration Date:
Job Site Address: Q�, ,�C1(�S"�`S Vj)!� Alt)U e 2 City/State/Zip: 11VC1141 �.�
Attach a copy of the workers'compensation policy declaration page(showing the policy num er and expiration date).
Failure to secure coverage as required tinder 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$250.00 a day against the violator, Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the.DIA for insurance coverage verification.
I do hereby cer if un a th
ature e pains andpenalties ofperjury that the informatihn provided above is true and correct.
Si Date:
Phone#:
Official use only.. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.BuiIding Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
DATE(MWDDIYWY)
CERTIFICATE OF LIABILITY INSU NCE 12/22/2011
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS PION THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE CO RAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN T E ISSUING INSURER($), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
ATION
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed, f SUBROG 15 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 Ileu of such endomemen s). '
PRODUCER N Christian Rarbe , CIC
Oceanside Insurance Group PAX
o . (508)175-0500 (508I790-7955
Oceanside Insurance Agency Inc AZIES8, ideinsurance.com
52 West Main Street INSURE 8 01-0 DINOCOVERAGE NAICN
I
Hyannis MA 02601 INSUREAArbella Prote tion Insurance
INSURED INSURERB:E'Vanston Ins to
Benabby, Inc. , DBA: Disaster Specialists INSURERC:
P. O. BOX 480 INSURERD:
INSURER E:
Sandwich MA 02563 INSuRERF:
COVERAGES CERTIFICATE NUMBER:CL11122102244 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURI iD NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER OCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBE HEREIN IS SUBJECT TO ALL THE TERMS
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIM .
R TYPE OF INSURANCE D POLICY UM L F P LIMITSL
GENERALLIABILITY EACH OCCURRENCE S 1,000,0 0
X COMMERCIAL GENERAL LIABILITY S lOO,O 0
A CLAW"ADE ❑X OCCUR X 8500039944 /1/2012 /1/2013 MEDEXP one on S 10, 0
H PERSONAL&ADV INJURY Is 1,000,000
Txi;ilment Coverage I GENERAL AGGREGATE S 2,000, 00
GEN'L AGGREGATE LIMIT APPLIES PER: I PRODUCTS-COMPIOPAGO S 2,000,00
0
X POLICY PRO L C Belilmentcavenge S 2501 00
AUTOMOBILE LIABILITY 1 aNUILL LIMIT
SI 000 00
BODILY INJURY(Per person) $
� ANY AUTO
AUTOS rEO X SCHEDULED 7018400003 /112012 /l/2013 I BODILY INJURY(Per aeGdent) S
R�AUTOS OPER DAMAGE y
X HIRED AUTOS X AUTOS�EO F
da
PIP•Baslc $ 8 00
X UM13RELLALIABHx
OCCUR EACH OCCURRENCE $ 1,000, 00
A EXCE38llAB CLAIMS�viAOEJ i AGGREGATE S S,000, OO
DIED X RETENTION 10,00 X 600038945 /1/2012 IvY2013 t S
WORKERS COMPENSATION , WCSI WIT
(Mandatory In NH) OT i
i
AND EMPLOYERS'LIABILITY
ANY PROPRIETORIPARTNERIEXECUTIVE YIN El,EACH ACCIDENT $
RY
OFFICERIMEMBER EXCLUDED? Lf N/A I
El DISEASE•EA EMPLOYE S
If yyes daut be under EL DISEASE-POLICY LIMIT i$
DMIRIPTION OF OPERATIONS below
1/22/2011 1/22/201�t EachOocurence 1,000, 00
B Contractors 1CPL00979 ,
Pollution Liability X ! Aggregate 1,000, 00
DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks SchaduA,B mote apace is required)
Workers Comp cart to follow directly from insurance carrier.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOV4 DESCRIBED POLICIES BE CANCELLED BEFOf E
THE EXPIRATION DATE JHEREOF, NOTICE WILL BE DELIVERED N
ACCORDANCE WITH THE PO ICY PROVISIONS.
- AUTHORIZED �REPRESENT E /4
I i
C Murray CIC/MC
ACORD 25(2010/05) 01988-2010 4CORD CORPORATION. All rights rese ed.
INS026(201005).DI The ACORD name and logo are registered marks of ACO D
RightFax N1-1 12/22/2011 7:19:42 AM PAGE 3/003 Fax Server
:11. .:s A ISSUE r ?;{ v y<ltp forEX
EX
5 It 12/2 212 Oil TE
THIS CERTIFICATE I8 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON DSM CERTIFICA HOLDER,THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED THE PDLICIF:S
BELOW T=CEArMCATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE IRSWNC INSURLIX(S),�V KORLT,ED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the po9cy(les)must be endorsed,if SUBROG TION IS WANED,subject to the
terms and condtilons of the policy,certain policies may require an andoraemea A statement on this certificate d as not confer rights to the
certNlcate holder In Heu of such endorsements.
PRODUCER CONTACT
OCEANSIDE INS GROUP NAME`
52 WEST MAIN STREET PHONE
No,Eta: �,No): '
HYANNIS,MA 02601 EMAIL
ADDRE53:
PRODUCaR •
CUSTOMER IV V.
INSURED INS S AFFORDING COVERAGE NAIC#
BENABBY INC DBA INSURER A ZURICH
DISASTER SPECIALISTS INSURER
P 0 BOX 480 INSURERC
SANDWICH,MA 02563
INSURER D
INSURER E
INSURER F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CER77FY THAT TEE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED To TIM INSURED NAMED ABOVE P R THE POLICY PERIOD INDICATED.
NOTWITHSTA.NDR70 ANY REQU1RMIENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOMME TT WITH RESPECT TO CH TADS CERTIFICATE MAY BE
ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED EIREDJ IS SUBJECT TO ALL THE TERMS, CLUSIONS AND CONDITIONS OF SUCH
POLICIES,LWrS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY E LUMT8
LTR DISR WV01 I
GENERAL LIABILITY , EACH OCCURRENCE S
MALOIAGETORENTED S
0 COMMERCIALOENERALLTABMM FREMSES(EVJ1 ..
accvrreaca t
Q CLAIMS MADE O OCCUR person PENSE(/my one S
0 PERSONAI,&ADV I
INJURY
0 1 OENERALAGOREGATE S
i
GEN'L AGGREOATELdMTTAPPLIMYER
PRODUCTS-COMMOP S i
QPOUCY OPROJECT OLOC AO0
AUTOMOBILE MABDJTY COMBINED SINOLF S
Lam
iffAoh seeidenl
0 ANY AVID BODILYINMY S
ar Psraa
0 ALL OWNED AAUTOSBODD.YINMY S
j (Por Acciderd)
0 SCHEDULE[)AUTOS PROPERTY DAMAGE S
Ter amtdent I
0 RIREDAUPOS S
0 NON-OWNED AUTOS - S
0
0 UMBRELLALIAB 0 OCCUR EACH OCCURRENCE
0 EXCESS LEAD 0CLAII-M-MADE AGGREGATE $ -
0 DEDUCTIBLE S
0 RvrnmaN s S
WORKERS'COMPENSATION WC .
A AND EMPLOYERS LIABILITY NIA STATUTORY
YIN LIhffIS
ANY PROPRMTOR/PARTHER1 I
EXECUmEOFIICERNMMER N NIA 6ZZUB41021>700 ON01112 01/01/13 LEACH ACCIDENT S500,000
EXCLUDED?
(NIMATORY INN D L DIREAM-EACH S500,000
I OYEE
i
Ups,dos"k radar DLSCR79ON OF L.DISEASE.POLICY $500,000
OPERATIONS below P
UESCRIPTIONOFOPERATTOIPB/LOCATtONBIVF.HICLES(Attach ACORD 101,Additional Remarks Schedule,ilmore space,,rdquiteQ i
THE.INSURED"i MA WORKERS COIOENSATTON POLICY AND ITS umr ED ormm STATES wmmmm ENDOREEImn AUTHORIZES TM PAYMENT'OF BENEFITS FOR CLAIMS MADE BY UIF.ENSURED•
EMPLOYEES IN STATES OTTER THAN MA NO AUTHORIZATTONIS OMEN TO PAY CUM FOR BENEFITS IN ANY STATE CARER THAN MA IF THE INSURED MM.OR HAS FARED,EMPLOYEES OUTSIDE �
MA.AUS POLICY DOES NOT PROVIDE COVERAGE FOR ANY MATE O MERTHAN MA
THIS REPLACES ANY PRIOR CEMMCATE 18SDE0 TO TTIE=71CATE HOL02R AFFECTING WORKERS C MP LJOVERAGE
aCgs3lT..; .1A,S�_.1���.�.<ssi,.+Iv..i,.�,•7TizzF:�.•.:,f.
SHOULD ANY OF THME ABOVE DESC 90 POLICIES ISE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,N TICE MALL SE DELIVERED IN
ACCORDANCE MATH THE POLICY PR VISIONS.
_.... AUIHOIIIIDMPRMENTATIVE
j •.,,,'ram [ Ya _ BrtawMaccLeaw p��y�'j� ��y�+ ,�.���•
i�l'�, 1(17F VQ9�Q.' :,°•'rjdi�:`.w�'.T,A." �c .:;.n'-r.., ;^`i'+'-MC "�.•s,e'k•..'+`s'a,.5Gy r ` '�..:5 .` t� 1[tY1'+C7L�arIYi..3 V�17C6CUY�Iti e'
i
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Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
Construction Supen�iwr
License: CS-071402
=- .
JO SHUA L C�E N
19
r.
1082 OLD S G i
R
C
CLN7CE �E
• ZA
Expiration
Commissioner 12/31/2013
Office of Consumer Affairs&Business Regulation License or registration valid for individul use or!,,
-' -' HOME IMPROVEMENT CONTRACTOR
before the expiration date. if found return to:
Office of Consumer Affairs and•Businr.is Regulation
Registration;a 108642 fYpe IO.Park Plaza-Suite 5110
Expiration 8/20/2012 Supplement i'ard Boston,MA 02116
BENABBY INC/DISASTER SPECIALIST
JCSH COHEN {
Box 480 —7
!
_
Sandwich, MA 02563 Lindcrsecrctr.r �'. Not valid without signature
.. q
j � Ta'ti Town of Barnstable
Regulatory Services
yMIAS& Thomas F. Geiler,Director
�A 16g9
rEvr�r►�� Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis, MA 02601
www.town.barnstablema.us
Office: 508-862-4038 _. _ Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A Builder
IeCA^ , as Owner of the subject property
hereby authorize /j S" IL to act on my behalf,
in all matters relative to work authorized by this building permit
(Address of Jo )
Pool fences and alarms are the responsibility of the applicant. Pools
are not to be filled or utilized before fence is installed and,all final
inspections are performed and accepted.
PA9I'w
Sao 79
sh
G�
a ature of Applicant
Print Name Print Name .
Date
Q:FORMS:0WNERPEPMISSI0NP00LS 62012 -
Town of Barnstable
Regulatory Services
SARNSTABrX, « Thomas F.Geiler,Director
MAS&
p� 1639. a.�� Building Division p�o�
Tom Perry,Building Commissioner
200 Main Street, Hyannis,-MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION:
number street village
"HOMEOWNER":
name home phone# work phone#
CURRENT MAILING ADDRESS:
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellinzs 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 buildingpemmit. (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 aperson(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:forms:homeexempt
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map aq�% Parcel Application # c�
Health Division Date Issued
Conservation Division Application Fee f
Planning Dept. Permit Fee \
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation / Hyannis
Project Street Address
Village _ ca 4&jy e
Owner )A Address Ld p At )
Telephone
Permit Request V 0L
A�s -oU , 9
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation�40PQ Construction Type
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units)c--
Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No
Basement Type: ❑ Full ❑ Crawl ❑Walkout C&�ther�4i,
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 Authorization ❑ Appeal # Recorded ❑
Commercial ❑Yes ❑ No If yes, site plan review#
Current Use . Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name / �% ��® 1 � Telephone Number
Address !d) "S-15A) License # 05 152
Home Improvement Contractor# %G
S CGhe v Worker's Compensation # y a n
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE
FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE -
OWNER
DATE OF INSPECTION:
FOUNDATION ,
FRAME
INSULATION
FIREPLACE
is
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
j
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO.
r
II
The Commonwealth of Massachusetts
.f Department o De art Industrial Accidents
P
' Office of Investigations
'- 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information `� n -� Please Print Legibly f �.,�(,
Name(Business/Organization/Individual): bbu i /i�� 1�1)�[� �(� t,����t �� 7S
Address: P y), Roy j-/ Iq j�w )T 1 Ute
City/State/Zip: WJ~ Phone#: 8
Are you an employer?Check the appropriate box: Type of project(required):
1.X I am a employer with 10 4. ❑ I am a general contractor and I
employees(full and/or part-time).*
have hired the sub-contractors 6. El New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. employees and have workers'
9. ❑ Building addition
[No workers' comp. insurance comp, insurance.t
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
insurance required.] 'r c. 152,§1(4),and we have no 13,❑ Other
employees. [No workers'
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
lam an employer iliat is providing worlcers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: Z
Policy#or Self-ins. Lic.#: Expiration Date:
Job Site Address: 02 City/State/Zip: de
�.
Attach a copy of the workers' compensatio policy d claration page(showing the policy n ber and expiration date).
Failure to segue 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 forin 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 cer if un a the pains and penalties of perjury that the informati6n provided above is true and correct.
Signature: 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/Town Cleric 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone M
RightF'ax 141-1 12/22/2011 7:19:42 AM PAGE 3/003 Fax Server
ct
M.
d��rr t Var Taf�a �!( rdf r ' sy, �rt(r;R.: ?YirK 15SUEDATE
,✓�r, .. 5<'^"l+ ,.w3:-- r tor:4:, 112/2011
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON TICE CERTIFICATIE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED THE POLICES
BELOW.TM CERTIFICATE OF INSURANCE DOES NOT CONSTFIUTE A CONTRACT BETWEEN THE ISSUING INSURER(SN hUTHORIZZD
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT;N the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed,if SUBROG TION IS WANED,subject t0 the
terms and conditions of the policy,certain policies may require an endorsement,A statement on this certificate d es not confer rights to the
certlflcate holder in Neu of such endorsements.
PRODUCER CONTACT
OCEANSIDE INS GROUP NAME`
52 WEST MAIN STREET PHONE FAX
Ext; (AJC,No):
HYANNIS,MA 02601 EMAIL
ADDRESS:
PRODUCER
CUSTOMER ID t.
INSURED INS S AFFORDING COVERAGE NAIL p
BENABBY INC DBA INSURER A ZURICH
DISASTER SPECIALISTS INSURER B
P 0 BOX 480 INSURERC
SANDWICH,MA 02563
INSURER D
INSURER E
INSURER F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO TINE INSURED NAND ABOVE P R THE POLICY PERIOD INDICATED.
NOTWITHSTAND0r0 ANY REQUA1E dE T!',TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMMiT WITH RESPECT TO CH TM CERTIFICATE MAYBE
ISSUED OR MAY PERTAIN,THE D46M NCE AFFORDED BY THE POLICIES DESCRMM BEDEW IS SUBJECT TO ALL THE TERMS USIONS AND CONDITIONS OF SUCK
POLtCBSS,LIbffTS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFP POLICY E LIMITS
LTR INSR WV0 I
GENERAL LIABILITY , EACHOCCURRENCE I
M
0 COMMERRC"OEN PRIAS E
ERALLIABILITY S EES(Each TAch ID S
occurceace +
MED,EXPENSE(Any one S
Q CLADAS MADE 0 OCCUR perian
0 PERSONAL&ADV I
INNRY
0 ) OENERALAOOREOATE S i
OERL AGOREGATELD4T APPLIES PER
' PRODUCTS-Cot lOP S I
U POLICY ❑PROACT 0 LOC AOO
i
AUTODIOARLEr..IARD.ITY COManMDSINOLE S
L IM
_ ch eedden i
0 ANY AUTO i BODILY INNRY I
i
er Perso i
0 ALL OWNED AUTOS I BODILYINJURY S
j (Per Aecident)
0 SCHEDULED AUTOS PROPERTYDAIIAGE S
er Midm0 i
0 RMAU•Ibs I
0 ITON•OWNED AU70S I
0
0 UMBRELLAUAB 0 OCCUR EACH OCCUM—ENCE I
0 EXCESS LVsB 0 CLAWS-MIDI
AOGREOATE S
0 DEDUCTIBLE I
0 REfEM'DON S S
WORKERS,COMPENSATION i WC
A AND EMPLOYERS LIABILITY NIA STATUTORY
YIN j LIMITS
ANYPROPRIEI'ORlPARTTFa' I _
E"Yp FRET" o�RTr N NIA 6ZZU84102P700 0)/01/12 01/01/13 LFACHAccIDENr IS00,000
EXCLUDLIX i
(MANDATORY IN NH) L DISEASL•-EACH s500,000
i
LOM
rr yes,descrk indm DL•SCRUMON OF i I.1)IMASE-POLIO!
OPERATIONS below T P500,000
UESCRIPTIONOFOPERA7ROr7S1LoCAT10NRN acLIS(Abch ACORDIOI,Addiliorul Remsrks SchedWe,jrmoresputirrequ'ved) i
THE U49UREDIS 1AAWORKERS COMPENSATION POLICY AND ITS LUArrED OTHER STATES INWRANCE ENDORSEMENT AUTHORIZES THE PAYMUrVOF BENEFITS FOR CLADM MADE DY THE NSURED'
DOLOYEES IN STATES OTHER THAN MA NO AUTHORIZATION IS ONFN TO PAY CLAIMS FOR BENEFITS IN ANY STATE OTHER THAN MAIM TiM INSURED HBU:S,OR XM 1RRED,EMPLOYEES OUTSIDE I
MA TH)S POLICY DOM NOT PROVIDE COVERAOE'OR ANY CIAT'E OTIERTHAW MA
THIS REPLACES ANY PRIOR CERIIlRCATE IASUED 70 THE CERTIFICATE HOLDER AFFECTING WORKERS C MP COVERAGE
+ I
SHOULD ANY OF THtc ABOVE DEBC 110 POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,N TICE VALL BE DELIVERED IN
ACCORDANCE MATH THE POLICY PR VISIONS.
Aunto&=REPRE1wtrAnw
:..:..........,..:..,... M
8rlawMasl.eaw
eo
i
Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
Construction Supen'lsor
License: CS-071402
JOSHUA L COAN
1082 OLD STAG
CENTERVIF3LE
Expiration
Commissioner 12131/2013
;t
*. Expiration",
ice of Consumer Affairs&Business Regulation
ME IMPROVEMENT CONTRACTOR License or registration valid for individul use only
;. before the expiration date. If found return to:
egistration 108642 Office of Consumer Affairs and Business Regulation
g/20/2014 Type 10 Park Plaza-Suite 5170
BENABBY INC/DISASTER,SPECIALIST Supplement(`:ard Boston,MA 02116
< zp
JOSHUA COHEN
Box 480 = M
Sandwich, MA 02563
Undersecretary
Not valid without signature
��tHEti Town of Barnstable
Regulatory Services
9snxivnaiE�+ Thomas F.Geiler,Director
s6gq. �0
'°rEDMA'1a 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, 41)),,141? V 11: vez I lzit —721/liM , as Owner of the subject property
hereby authorize �isG.T - eci ' t, r k 4.00 c, to act on my behalf,
in all matters relative to work authorized by this building permit.
(Address of J b)
**Pool fences and alarms are the responsibility of the applicant. Pools
are not to be filled or utilized before fence is installed and all final
inspections are performed and accepted.
�o
S afore o wner ature of Applicant
V
Print Name Print Name
Date
h
Q:FORMS:OWNERPERMISSIONPOOLS 6/2012
1
�t"E,�,. Town of Barnstable
"�.oll
Regulatory Services
x r
UMMSrAsze, « Thomas F.Geiler,Director
MAS&
A i6s9• A`�� Building Division
rFD MA'I
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION:
number street village
"HOMEOWNER":
name home phone# work phone#
CURRENT MAILING ADDRESS:
city/town state zip code
The current exemption for"homeowners"was 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 th6 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
• ., 4` .. *c..,d� •, .t` ;sit ."+ •• h �k` \ �
a ,
Approval of Building Official t
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 �y
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 persdri(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 caret amend and adopt such a form/certification for use in your community.
Q:forms:homeexempt