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HomeMy WebLinkAbout1225 IYANNOUGH ROAD/RTE132 (13) i�as .��-r►�o��h ��t . -- � �-- -- ,�� �� ;, X f Ll ow1w lmd&j UNV-12122 MADE IN USA SUSTAINABLE MR RECYCLED CONiENi 10% Certllbdfbw8oureing POST-CONSUMER IgwairglogfamArg l"1190 t TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map c I Parcel 0 Application Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address /Z ZS— =rV4--.,- ✓�J / 4-2-/ Village//v4 S' Owner C s� �� e� s��� Address Sh.gti Telephone ,5-0 7 7 / a 4-1-d Permit Request 4alee.c-c... Alae;✓ 0,-I e1ciJ�Zy S�i s��� �e-5�.�� L� mi4,r5r,r �ouAs Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation-3�Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) : m_ ZE Age of Existing Structure Historic House: ❑Yes ❑ No On Old Kino Highway:,'❑Y� ❑ No ti Basement Type: ❑ Full ❑ Crawl ❑ Walkout ❑ Other � _77 Basement Finished Area(sq.ft.) Basement Unfinished Area (sq Number o1Baths: Full: existing new Half: existing r.w Number CA 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 Co ti s C �r�r+.c��c. �� -f/: Telephone Number 2 " 7/ 2-S,- Address 3,'y_ G al-i - Ceti),-r .51 License # G J - 0 Home Improvement Contractor# /V/X Email i w"/sd, G'4s cd�s ec C_o^ Worker's Compensation # �°"SaoB�YS�Zo/y�9 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO A p �✓�y lsya.e��.�.f /�l/� SIGNATURE 41Z DATE /1/d %� 4 S FOR OFFICIAL USE ONLY r APPLICATION# DATE ISSUED � 4 MAP/PARCEL NO. I ADDRESS VILLAGE I -- OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL I PLUMBING: ROUGH FINAL GAS: ROUGH *FINAL I. - FINAL BUILDING y M DATE CLOSED OUT ASSOCIATION PLAN NO. 4 w Crammoanwaldt of Massrachaseffs Departtrwt rf Industrial Accidents - - tie Of nvestiglff6ans .. 600 W ras-hiravan,meet . Bzstan,MA 02H a www.znass.g-r, mica Annikant Tnfarmation / Please Print:Legibly Name _ <,S r Co<s� �cin�+crci�� •sfir�c�.r 2.,� Ad&e-s� ?F!`^ ,wed S;,y,o4 City/S;at&tp_ Gu �� Phone Sa -3 z S- 71 z Are you an employer?.Check the appropriate bay: yk of_ ect s 4. I ama confractcsr and i PToi " (e#1��= 1_ I am a employer with 6 ❑ b_ New coz E=�oa e�loyees{fud andlor part-ime}* have hired fhe sub-contractors. �_❑ I am a sore proprietor orpzriner- listed on the attached sheep _ Remodeling ship and halve no employees These sub-contractors have 8- ❑Demolition worlzivg for me.in any rapacity_ employees and have workers' 4_ ❑$uildmg addition [No workers' Qon7p:insurxrre " comp_insurance I McFlired-] 5.0 We are a corporation and its Io_0 Electrical repairs or additions 3111 am a homeovuer doing all work officers lamm exercised their. 11_.0 Plumbing repairs or additions myself [No wormers'comp_ right of e�-.!mpfion per MGL 12_ c-152, 1 and we hnme no �Roof i i iraTnc-�1'e.(�v.7Z d-� �t�tl.^ N �ccce. r_f' employees-[No ' 13-©Other comp_Insurance req'ured.l *Any aapHrnt that cbPcks boa fl nwst also fM otg tha section beIDW sag tlreir�o er3'[o tiou Fob infra . T ffnmemwnem who submit this atfi x ir,,F xCmF they.are doing an vrw and then hire OUtd a contraeturs mu M)ZI ZO=tmctars tbst cheek this box mast sttached sa a3ditinnxl street shozr-img the name off the sdct c=k2Cb3Z6%nd state achether geliot fbuse hies have emplu e - If the snbcontmctzas h-.-ca employee.%they—st pmvide tter Workers'comp-policy number- -Tam an empLoyer that is prmid&W work-ar-s'comperrscrtio.n arrsrtraace far my,empLayegm ReLuiv is the pQlir and,tob site In��aranceGouipatiyNamt:_ /-�•l-/t'1-- /t��i��w-l1'.-sur'=.^ems. C._o•►�/,��r-� Palley ti of Set€-ins_Iic Wre-5W"5EV8 c}Yr-2-y I y.A ExpirationDate_ 22 tv sine✓ h /`d /� cnni� /°�/`T t✓i lSfafz! �7 Sn/ti1 /� Io�r Sites ems_/ Y y Attach a ropy of the workers'compensation policy declaration page(shoving the policy n-a i>ber and empu-ation date). " Failure to secure ca mrage as regal under Section 25 A o€MGL c 152 can lead to the imposition cf critninaT pen�ftios of a fine up to s 1,5oa.oa audlor one-year impfisonmenty s s wen as civil penalties in$ie foam of a STOP WORK ORDER and a fine ofup.to$250-00 a day against the violator_ Be advised that a copy of this eatement maybe fhrwarded to the Office of Im;e*ptions of ffe,DIA for inexsrnee coverage verification - I dd hcrreby certify rttrder t#e Irlrlpenatftas nfp@tjtrty thatrtfhe irtformationprcni&d ab.z see i t b7m and correct n" QAiciat use only. Da trot rt'ritg in tills area,to bs COMP&ted by cio or tawn official City or Town: permit Licertse# Issuing r'1_uthority{circle one}: I.Daard of Health 2.Ruff ling Department I City Town Clerk 4_Elecbacal Inspector S.Pkrdbing Empector &Other Contact Person: Phone# 6 Information and. Instructions Massachusetts Central Laws chapter 152 requires all employers to provide workers'compensation for their employees. pursuantto this sta-torte, an employee is defined as".:_every person in the service of another under any contract of hire, express or implied, oral or wiittea_" An employer is defined as"an individual,partnership,association,corporation or other legal entity,or rift'NYro or more of the foregoing engaged in a joint enterprise,and mcludiag 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 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 Iocal licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the common e-Alth for- airy 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-contractors)name(s),address(es)and phone number(s) along with their certinc- (s)of insurance. Limited Liability Companies(1-.LC)or Limited Liability Partnerships(T_LP)with no emnloytts other than we members or partners,are not required to cant'workers' compensation iumaranCe. L an LLC or LLl does have employees, a policy is required. Be advised that this affidavit may be submitted to the Depa--taient of industrial Accidents for confirmation of in ur-ance coverage. Also he sure to sign and date the affidavit '11e affidavit should be retumed to the city or town that the application for the permit or license is being requested,not the DepartL*nent 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 oa 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 BE 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 cumber. In additica.an applica it that must submit multiple pernitflicease applications in any given year,need only submit one affidavit indicating=ent 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 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 bore owner or citizen is obtaining a license or permit.not related to any business or commercial venture (Le.a dog license or permit to bum 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 shouldyou have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: Tho Commanwealth of Massachusttis Depaitm.ent of ladustrial Accidents 0,LMce Of Iuvestigatiam, 500 wa shire an met BastQn,M&42111 Tel.A 517 7-49-00 ext 4Q6 or 1-&77 MASSAFE Fax-517-727-7149 Revised 4-24-07 DATIS(MNIIDOl"VYI Aca CERTIFICATE OF LIABILITY INSURANCE 2/2.5/2014 IS THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND C OR ALTER ONFERS NO RIGHTS UPON-- AFFORDEDHE ABY TTE HE POLICNE9 CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. ATION IS IMPORTANT: I( the Certitleete hod r l an ADin pD TGO Policies INSURED,re the endalr)(106) 11lual l A at lament on this ce►tlftOsle d os not WAIVE ), $)to the the terms and conditions of the policy, certificate holder In lieu of such endorsements• Laura 4Fismnez PRODUCER PHONE (508)23B"0056 FAX . ISO61:!30-8�67 Morse Insurance Agency, Inc. lauzswiesnezCtmoxseins.com 285 Washington Street NAICN INIUR9111till AFFORDING COVERAGE —" North Easton MA 02356 INSURERA.WaUtilUa Insurance 1001� INSURED INSURERO-Arbella Indemnit - -- East Coast Commercial Construction Inc. INSURER cEv9neton insurance CO• 389 West Center Street INSURERDAaeociated Em to ere Ina. Unit S. INSURE E: - West Bridgewater MA 02379 INIUR F COVERAGES CERTIFICATE NUMBER.2014-2015 Master REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO-THE INSURED NAMED ABOVE: FOR THE POLICY PLIRIOD INDICATED NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT 10 WHICH THIS CERTIFICATC MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO AL_ THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR POLI Y EF IPOL ICY ERF LIMITS LTR TYPE OF INSURANCE POLICY NUMBER I IYVYV 1,000,00 0 EACH OCCURRENCE S GENERAL LIABILITY DAMAUt 10 MtN I S 100,000 P , _ X COMML•RCIAL GENERAL LIABILITY $ 000 /24/2014 /21/2015 MED ExP(Any one venom S _ A CLAIMS-MADE Y OCCUR 381600 1 000,000 PERSONAL&ADV INJURY S GENERAL AGGREGATE S 2,000,000 PRODUCTS-COMPIOP AGG S 2,000,000 GENT AGGREGATE LIMIT APPLIES PER' S X POLICY PRO LOC - AUTOMOBILE LIABILITY 1_r 000 000 BODILY INJURY(Per peroon) 11 ANY AUTO H 20 2014 /24/2015 pODILY INJURY(Per ecoeonl) S AUTOS NCO X AUTOSULEO 1020014594 / / •--- PR TY DAMAGE $ X NON-OWNED PeI accR enl — HIRED AUTOS X AUTOS X UMBRELLA LIAO X EACH OCCURRENCE S 5,000,000 GccuR $ 5,000,000 C EXCESS LIAR CLAIMS-MADE AGGREGATE FXBCOD01617 /21/2014 /24/2015 S OE FTr:NTIONS A U- 1 j� WORKERS COMPENSATION X AND EMPLOYERS'LIABILITY YIN E.L EACH ACCIOENT S _ 50 0 A 00 ANY PROPRIETORIPARTNERIEXECUTIVE NIA CC500B945012014A /24/201A /24/2015 E.L.DISEASE-EA EMPLOYE S 500�000 (Mandatory)n NH) If pee,describe under E.L.DISEASE•POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (AMach ACORO tOl,Addlllonal Remarks Schedule,it,nore apace Is requlnd) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEPORE THE EXPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVIIION8. AUTHORIZED REPRESENTATIVE - � I Laura Riesnsz/LMP1 416�L_W-Q—j�> 't��"�"r ACORD 25(2010106) 01906.2010 ACORD CORPORATION. All rights reserved. INR07F �n+nmm�+ The armor Home nnr4 Irnnn Pro reniafararlrnarlr•of a/'nDr1 O • BARNSTAB[.E, # 1619. ,0� Town of Barnstable Regulatory Services Richard V.Scali,Director Building Division Thomas Perry, CBO 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 —k4/If 0,— as Owner of the erro subject � r r ti hereby authorize 0 k1l, (�,`�soI-\ to act on my behalf, in all matters relative to work authorized by this building permit application for: 1 Z z 5" , r2J (Address f Job) Signature of Owner Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. QAVYTFILES\FORMS\building permit fomis\EXPRESS.doc Revised 061313 Massachusetts Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-043997 ! JOHN T W H SON-` 389 WEST CENTER a } W BRIDGEWATtR MA��'0�2�3/M `)1,0`� Expiration 10119/2015 _ � Commissioner 1 EPOP,S:004107-353029 ********************* CUSTOMER COPY ********************* Page: 1 1409161104 BIC2020 10/30/2014 QUOTATION #77 Beacon/Cranston Sim#: .004107 730 Wellington Ave Emp: Cranston, RI 02910 Entered: 10/28/2014 Phone: 401-467-8870 Xmitted: Fax: 401-941-5240 PO#: "Customer.#; 6003 Job Name:East Coast Home Owner:. Beacon/Cranston Project ID: 730.Weilington Ave Location: Lot#: - Cranston, RI 02910 Model: Phone '401-467-8870 Contact: Fax: 401-941-6240 Cust PO#: Ln Qty - I . L6 Ord Long Description No 01 84 72"-(0)X 80" (0)(6068) ProFinish Brickmould 600 White Right Opening DR Unit : Extended: OX;tint. Handle White; Ext. Handle White; Rough Opening Size; BM; Price Price Intercept; ProSolar Low E; Argon Gas; Double Glazed; Temper All All; Double Strength (1/8"); Half.Screen Fiberglass Extruded Screen Mold; E5 All Stiles 546.00. 45864 00 (SUEV).; Tape Applied; Non-Keyed Locks; Corrosion Resist Roller/Glide (1.111=152"); DP:3.5; Test Number=D2892.01; U-Factor:.28; SHGC:.30; Unit qualifiesJor ENERGY STAR®region(s):.Northern, h Central, South Central,Souther; Room ID: Free 3.5" Casing SO di EAST COAST COMMERCIAL CONSTRUCTION`INC. 389-G West Center Street West 9ridgeW ter, MA 02379 `n (508)4274400 6 Fax (508) 427 6.600 f ; . p _ > • JOHN WILSON President Commercial Construction 9 389-G West center street _ West Bridgewater,MA 02379 jwilson@eastcoastcommercialconstruction.com Tel:508.427.6400 Ext.102 www.eastcoastcommercialconstruction.com Fax:508.427.6600 I FAX uOm""VERTAGNE ATTx: — - FAX: FRDM: RE; - PAGES: indudigg 000v� G Umai D mor MWAOW D'feww Cast O mmm ftph► r. comber 1 s. rc am wto 08mv awe. A A OtZrw T*ML4v:141Qb Commercfal'Conotruotlon 1 Aid.- C JOHN WILSON '71 Z President Commercial Conaeruerlon 38M West Cantor Strew West 9R694water,MA 02379 rwnsontleeateoestcammercielrnnetruetlon.com Tell 608A27.6000 B a.102 WWW.eesteoasteommercialconstructlon.com POWS08427.6600 MassachusettsI -Department of Public Safety Board of Building Regulations and Standards Construction Supei-visor License: CS4A3997 JOHN T W[LSok-'• •�, 389 WEST CENTER W BRMGEWA7�R J12. �rnt'% Expiration _ Commissioner 10/19/2015 389-C West Center Street West Bridgewater, MA 02379 Tel: 508.427.6400. Fax: 508.42 7.6600 TOTAL P.02 I TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION 1� Parcel Map 'p ? 6'Z 4ptali-on Health Division Date Issued g Z 3—yf". Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address ZZ Village Owner_, f�Gr 7VA , l t� Address Telephone Permit Request lU la nwj 54 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type.. - Lot Size Grandfathered: ❑Yes ❑ No If yes, attac .-. pportinTA-docuEPntation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes o On Old Kin'N Hi hw ❑Y ❑ No g g ❑'� g Basement Type: ❑ Full ❑ Crawl ❑ Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sgft) Number of Baths: Full: existing new Half: existing nP-w 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 l (BUILDER OR HOMEOWNER) Name 1 71 SG) A P6mo Telephone Number -)& '7U Z f L/ Address License # l"A10A tM�n nZ Home Improvement Contractor# L il 'Pthyn GrlYVSI-!� �kj)_Z tut) ,We Worker's Compensation # CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO NATURE DATE � I I FOR OFFICIAL USE ONLY APPLICATION:# k DATE ISSUED, MAP/PARCEL N6 i ADDRESS 1 VILLAGE OWNER j F DATE OF INSPECTION: _i i FOUNDATION FRAME INSULATION FIREPLACE .J ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FLNAL BUILDING D,ATEzCLOSED OUT AS�P,OfkTION PLAN NO. Ir , The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations ' 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers Applicant Information / Please Print Legibly Name(Business/Ommization/Individual): ebm m / ae f �Di`tim;�a Address: 3ob �yll1'inr S� City/State/Zip: ad/w[A- Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.[� I am a with employer 4. ❑ I am a general contractor and I �— 6. El New construction employees(full and/or part-time).* have hired the sub-contractors 2.El 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.i 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.]t C. 152, §1(4),and we have no employees.[No workers' 13.❑ Other comp.insurance required.] *Any.applicant that checks box#1 must also fill out the section below showing their worker'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. I am an employer that is'providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic. Expiration Date: 1 2,L /S Job Site Address: I ? "Gl- City/State/Zip: M )iI S� 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 insurance coverage verification. I do hereby r the p and penalties of perjury that the information provided above is true and correct Sismmature Date: S hs il P ne cial 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 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( )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-contractors)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 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 penmit/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 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.obtamiag a license or permit not related to any business-or commercial venture (Le.a dog license or permit to bum 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 Department of Industrial Accidents office of Investigations 600 Washington Street Boston,MA 02111 Tel,#617-727-4900 ext 406 or 1-877-MAS9AFE Revised 4-24-07 Fax#617-727-7749. ViWW.1n=.gov/dia �=I REDMA-1 OP ID: MB CERTIFICATE OF LIABILITY INSURANCE DATE CERTIFICATE 05/13/14 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(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). NTACT PRODUCER Phone: 781-749-4310 NAME: Walter J.May Ins.Agcy.,lnc. PHONE FAX 188 Whiting Street Fax Alt No Ext: AIC No Hingham,IOTA 02043-9840 E-MAIL Jeane M.Bortolotti ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Travelers 39357 INSURED Redman Construction,Inc. INSURER B:Commerce Insurance Company 34754 300 Whiting Street Hanover,MA 02339-1.314 INSURER C:Renaissance Insurance Agency 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 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 DDL UBR POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 500,00 A X COMMERCIAL GENERAL LIABILITY 6609235L664 01/17/14 01/17/15 PREMISES Emm"aoccu ante $ 60,000 CLAIMS-MADE �OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 500,000 GENERAL AGGREGATE $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ . 500,00 X POLICY PRO- AUTOMOBILE $ AUTOMOBILE LIABILITY Ea accident)SINGLE LIMIT $ B ANY AUTO BDWKJH 04/14/14 04/14/15 BODILY INJURY(Per person) $ 100,000 ALL OWNED SCHEDULED AUTOS X AUTOS BODILY INJURY(Per accident) $ 300,00 X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident 100,000 UMBRELLA LIAB HOCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- I OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER C ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N W00002449 01/26/14 01/26/15 E.L.EACH ACCIDENT - $ 100,00 OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEd$ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) JOB: 1225 IYANNOUGH RD HYANNIS MA 02601 CERTIFICATE HOLDER CANCELLATION TOWNBAR SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Barnstable THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Dept ACCORDANCE WITH THE POLICY PROVISIONS. 200 Main Street Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD THET Town of Barnsfi ile _ p • Regulatory Services g •IUchard.Y Sca14 Interim Director- _ t63q. �0 Building Divmon Tom Perry,Bui ding Commissioner: Zoo Main Street;Hyannis,AMA 0266i WWWAown.barnsfnble ma.us Office: 5*862-4038 Fax '508-790 230' Property OWtder Must Complete.and Sign This Section. If Using A Builder x as Owner of the subject P19P9 hereby authorize to act on'my behil in Alt matters telatire to`work authorized by this building per++* (Address of Job): Pool.feis 'es and alarms:are the responsibility of the applicant. Pods are not to be filled of utilized before Atice is .stalled and all final inspections are performed Arid accepted. Signature of.ownet Signa f Applicant Print Name :PrintN me • _ '.Date -- .., I, Mass aohus6ftt Abepartmerit of Public Safety k �Bdard,bf Bual i�r uRegulations and Standards { { la _ fR i nti�ru�im ~Supervisor... .:. License".G1S-0ovfuti JOSEPH M REDMAN 300 WHITING S EREE HANOVER MA 0233xo 'Expiration Comriii5sione,- 0.7/1512094.,