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HomeMy WebLinkAbout0027 JENNIFER LANE ' 9 1 tTHWE Town of Barnstable *Permit# yp� Expires 6 months fr issue date Regulatory Services Pee 4e MASIM Thomas If Geiler,Director l7 i639• Building Division Tom Perry, CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-962-403 8 Fax: 508-790-623 0 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-P ess Imprint Map/parcel Number (1�7j Aj Property Address (A , Amos up- 0,*0 residential Value of Work 41 ®f:�!-(�t� Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address At.th"d a 1«U: Contractor's Name 14 LTrzo Aaowul Telephone Number �be-uo-nZ���J Home Improvement Contractor License#(if applicable) 110 7 Construction Supervisor's License#(if applicable)[Q ' 6Workman's Compensation Insurance BAN 2 7 2012 Check one: ❑ I am a sole proprietor , I am the Homeowner TOWN OF BARNSTABLE I have Worker's Compensation Insurance Insurance Company Name � �e ,Ul SCGt� f'"� C-U(zwCe k 0 yu ,-TV4 Workman's Comp. Policy# Oft{ 6 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) Re-roof(strippinglold shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going-over existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders. U-Value (maximum.4-4)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,*i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License& Construction Supervisors License is required. IGNATURE: 1WPFILESTORWbuilding permit formslEXPRESS.doc ;wised 070110 I 4 -'� Massachusetts - Deparfinent of Public SufetN "Board of Building Regulations and Standards . Construction Supervisor License License: CS 102600 Restricted to: 00 DZMITRY LABKOVICH 13 ATHENS WAY WEST YARMOUTH, MA 02673 Expiration: 3/27/2013 fi'ummissi mrr Tr#: 102600 Office of Consu- �r� ness egu a o License or registration valid HOME IMPROVEMENT CONTRACTOR before the expiration date. If foundividurn ul use only Registration :170787 Type: Office of Consumer Affairs and Business Regulation Expiration 12/1 1..0/2013 LLC 1,0 Park Plaza-Suite 5170 R NG AND SIDING OF CAPE.COD,LLC. Boston,MA 02.116 v+ ! DZMITRY LABKOVICBj -_1y 68 WINSLOW GRAY RE 29 ' W.YARMOUTH,MA 02673 �1 / Undersecretary `s✓/ c�'!il/v Not valid with()/ signature s � The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 '' • www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information C Please Print�L/eibl Name(Business/Organization/Individual): . ZC0 JUGt" zd C.—c ' Address: 6& U1 MS' City/State/Zip: LJ. YJf Phone.#: �' ��0�02 9 Are u an employer?Check the appropriate bgx: Type of project(required):' am a employer with 4. 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 g• ❑Demolition workingfor me in an capacity. employees and have workers' Y p tY• 9: ❑Building addition [No workers' comp.insurance comp.insurance.$, 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 l 1.❑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 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. �'_f ( _ Insurance Company Name: �%N 1 ����e [. 1 •i-per � `C � 1�� Policy#or Self-ins.Lic.#: WC 6-XI Expiration Date: Job Site.Address: 21 J Qhh 16 lit City/State/Zip: Pjaymm� 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 Signature: Date: f' 7. Phone#• Sof %Q -_ 7�g 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 hiie, 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 produce&acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states`Neither the commonwealth nor any of its political subdivisions shall enter into any contract for.the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"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 obtaining a license or permit not related fo any business or commercial venture (i.e. 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 Massacbusetts Mpartment of Industrial Accidents Office of Inlvestigat oas 600 Washington' S.tre.0 'Poston,MA 02111 Tel.#617-727-4900 ext 406 or 1-S77-MASSAFE Revised 11-22-06 Fax## 617-727-7749 www.mass..gov/dia 1 , 0 CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 101/27/2012 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). PRODUCER NAME: Schlegel 6 Schlegel Insurance Brokers Inc PHONE (508) 771 -.8 81 FA 508 771 - 0663 34 MAIN STREETE-MAIL o,Ext): (A C,No):( ) ADDRESS: PRODUCER CUSTOMER ID#: West Yarmouth, MA 02673 INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERAGRANITE STATE Andrei Yarmalovich Dba Bel Island Home Improvement INSURER B: 29 Mill Pond Rd INSURER C: INSURER D: - West Yarmouth, MA 02673 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 POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DDIYYYY) (MM/DD/YWY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $ _DAMAGE_ ENTED COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence) $ CLAIMS-MADE F-1.OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ i GENERAL AGGREGATE $ GEN JECT'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO LOC - $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO $ (Ea accident) BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) - $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) $ NON-OWNED AUTOS $ $ UMBRELLA LIAR HTOccuR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE RETENTION $ $ A WORKERS COMPENSATION WC-0024627 02/25/11 02/25/12 }[ WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ lOO,000 OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) - - E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) ANDREI YARMALOVICH HAS ELECTED TO BE COVERED ON HIS WORKERS COMPENSATION POLICY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered s of ACORD dETME Town of Barnstable Regulatory Services MAMs Thomas F.Gefler,Director i639. �� 3 Building Division Tom Perry,Building Commissioner 200 Main Street;Hyannis,MA 02601 www.town.barnstable.maxs Office: 508-862-403 8 Fax: 508-706-6230 Property Owner Must Complete and Sign This Section If Using A-Builder ` � �� ,as Owner of the subject o - lect property Pert9' hereby authorize fc" :�1t 1�v�]C/L 'to act on my behalf in all matters relative to work authorized by this building permit (Ad ss of Jot) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled before fence is installed and pools are not to be utilized until all final inspections are performed and accepted. s - 17 Signature of Owner Sire - t2 of App cant Print Name Print Name Date Q:F0RMS:0VR4MERJv0SI0NP00IS G�tie Town :of Barnstable Regulatory Services Thomas F.Geiler,Director 1639 Fc N,►►+" Building Division Tom Perry,Building Commissioner 200 Main Streets Hyannis,MA 0260I www.town.barnstable.ma.us Office: 508-862-4038 Fax; 508-790-6230 4 Property_ Owner Must Complete and Sign This Sectionf If Using A Builder I, /!L'�l as Owner of the subject property hereby authorize k6& y/,Vc g�4 CIe ( GX_ tt(- to act on.my behalf, in all matters relative to;work authorized by this building permit. 7 h14 (Address of job) Pool fences and alarms are the responsibility<of the applicant. Pools are not to be filled before fence is installed and pools are not to be utilized until all final inspections are performed and accepted. Signature of Owner, Signature of App cant DlT " 14OVIC41 g y C Print Name Print Name Date . Q TORM&OWNERPERMISSIONPOOLS 'IKE Town of Barnstable Reguiatory Services BARNErrABLE, Thomas F.Geiler,Director �►tnss. �[ i639• . Building Division ArEo a 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 the building permit (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 115) 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. s 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:forrns:homeexempt