Loading...
HomeMy WebLinkAbout0032 KEEL WAY YOU WISH TO OPEN'A BUSINESS? For Your Information: Business certificates (cpst$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town.(which you. must do by M.G.L. it does not give you permissiori'to operate.) You must'first obtain the necessary signatures on this'form'at 200 Main St:, Hyannis, ' Take the completed form to the Town Clerk's OffiCe,.1•st FI'., 367 Main St., Hyannis, MA 02601 (Town'Hall) and get`the Business Certificate that is required �y law. DATE:Acl, "05-15 Fill in' lease: APPLICANT'S YOUR NAME%S: J,45vA M, BUSINESS YOUR HOME ADDRESS: s / 3a �('26/ ✓A� Bann � Cam% Y.�ft l ,,. �ti:&r6f �3'•"514 TELEPHONE # Home Telephone Number 77Y-YY7''7-343 NAME OFCORPORAT IOIV - NAME`OF NEW BUSINESS'•, ,2: sSY?r:..Er•. .� ce. 'NQ.�dy��h. St�r.u�t -:TYPE OF:BUSINESS:' 4)1,TV ati•.: y �• .. 4'.J u',i.: ._:.vy • .. .y. IS THIS:A CCUPATIO V. • 'HOMED I .. .:...__ YES.: , ...._ O. s�..•.. . . .. ..... :..: ... .,..:.:: •=r'::'` _ . _ : DD .. 5... :S_.:��.....:..,,•. .. . : : ..............:•.. :_.•_... : r.. ,-: ....: •%;:;;.��:A RE5$.O.F.,Bl�51NES •...::.. . . :....�.:,.......,.. _ RCEL NUM ��r �.�, •, . r.;�i•MAP/PA BER: Assessr When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town'of Barn stable. This form is intended to assist - sis you in obtaining the information ou may need. You MUST GO TO 200 Main 5t. (corner of Ya n rmou t h Y g Y Y ( .. Rd, & Main Street) to-make sure you have the appropriate permits and licenses required to legally operate your business in this town..* 1. BUILDING CO MISSIO ER'S OF CE This individual he e n.uzfor o• a per it e uirements tha pertain to this type of business: . MUST COMPLY WITH HOME OCCUPATION Aut on Si natQr * RULES AND REGULATIONS. FAILURE.TO ;.. C M EN : COMP .Y MAY RESULT IN FINES.* .. _ �� car (I/J h. 7. 2.' BOARD OF HE LT Thisiv' - individual has- been informed'of the er it re uire e is that erta' t this m m n ha in o is a of business. P q P type .. Authorized Signature** COMMENTS: . 3. CONSUMER AFFAIRS (LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: Town of Barnstable Regulatory Services o Richard V.Scali,Director' s * uaxsrest.E, Building Division �. suss g Tom Perry,Building Commissioner 1639. 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Approved: Fee: _ 4 Permlt#: czl�o L2 �� p HOME OCCUPATION REGISTRATION Date: 9,2-OS-/f Name; Jason 4/1k se Phone#: 77Y-!17 Y3V Address: 32 /('eel ✓ Village:AYGnni'S Name of Business: 9nO"ZinaA ,5&,V,�e j Type of Business: y4h46 Ar Map/Lot INTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation within single family dwellings, subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the activity shall not be discernible from outside the dwelling. there shall be no increase in noise or odor;no visual alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes; and no increase in air or groundwater pollution. After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to the following conditions: • The activity is carried on by the permanent resident of a single family residential dwelling unit,located within that dwelling unit • Such use occupies no more than 400 square feet of space. • There are no external alterations to the dwelling which are not customary in residential buildings,and there is . no outside evidence of such use. • No traffic will be generated in excess of normal residential volumes. • The use does not involve the production of offensive noise,vibration,smoke,dust or other particular matter, odors,electrical disturbance,!heat,glare,humidity onother objectionable effects. • There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess of normal household quantities: • Any need for parking generated by such use shall be met on the same lot containing the Customary Home Occupation,and not within the required front yard. • There is no exterior storage or display of materials or equipment • There are no commercial vehicles related to the Customary Home Occupation,other than.one van'or one pick-up truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lot containing the Customary Home Occupation. • No sign shall be displayed indicating the Customary Home Occupation. • If the Customary Home Occupation is listed or advertised as a business,the street address shall not be included. • No person shall be employed in the Customary Home Occupation who is not a permanent resident of the dwelling unit I,the undersigned,have read and agree with the above restrictions for my home occupation I am registering. Applicant P Date: Homeoc.doc Rev.103113 0 + � MCCARTHY ' RUCTION COo esi Elal and,Commercial Buildeu 1^+# a� ''' EAR RATIONJpEClAL�STF � QUALI-IFNA—LAW I March 15, 2014 G ZE ;zs Town of Barnstable Thomas Perry CBO Building Commissioner ' 200 Main Street ; -0 d Hyannis, MA 02601 RE: Insulation Permits Dear Mr. Perry, r This affidavit is to certify that all work completed for permit application#201200454;Status A;Parcel + 268209 at+32TKeer11Vay,Hyannis; A--Permit Type RADD and issued on 12:00:00 AM has been inspected by a certified Building PerformanceInstitute (BPI) inspector.All work performed meets or exceed Federal and State requirements Sincerely, f Michael McCarthy McCarthy Construction 1 + + a I - Town of Barnstable t �p�'oFtHE TOwy Permit# Expires 6 months from issue date Regulatory .�, Se BARM„BLE, # 1'Vlces Fee ! �� 9 �: ���� " Thomas F. Geiler,Director iOrFo Mai Building Division Tom Perry, CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-623 0 EXPRESS PERMIT APPLICATION - REsr-DE NTIAL ONLY Q ,,cam Not Valid without Red X-Press Imprint Map/parcel Number Property Address t K` L .°/1 l!_y APL ut�91 - residential Value of Work / � ' �'U Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address rc-/1 1 r 1+ 4,��s , . �=zL z���� l�y���� z .5 poA 6a6E6 Contractor's Name_ ram' ]JV / 0v-T__�{ Telephone Num ber 1g66 z �l z l / Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable J % ®��?PRES—S PERMIT s- ❑Workman's Compensation Insurance Check one: FE=B 1.4 2013 ❑ I am a sole proprietor ❑ lam the Homeowner [- have Worker's Compensation Insurance TOWN OF BARNSTABLE Insurance Company Name 1'4 �- -� t 2 e Workman's Comp. Policy#_ L-0 C ,�76 C/ Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side F#of doors o2 f' �}4 [ Replacement Windows/doors/sliders. U-Value (maximum .44)'#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 th Aome Improv e t Co actors License& Construction Supervisors License is requ' SIGNATURE: �AWPFILESIFORMSIbuiIding permit formslEXPRESS.doc Revised 070110 The Comwnw atthinfMus�ackjaeit. Depar.�z�Kt rf'�ndur#rur��ccide�tis - �,fc Qf joertiioiu� ... i 660 Washktop Sftet; Boston,CIA QV1 w"nP Mass gon4d a Workers' Compeasatdon Insura;ace AM $pit:`Sunders/Contractors/Electirx..ilut Plumbers 1 :inoheant Inl`ormafiala Please Pout Le l i } C� � +�' Name.(Bitsinessd0rgeni28tion/Individual):; e ,�,o ry � na L C Andress: -i- �- City/Si&te/Zip~ Wojoz)rr �M,9 (D1 6_Cor. Phone 100 A-re you an employer?Check the appropriate bog. Type of project(required)': P Y 4. 0 Lam a general contractor andf I am a employer er with, Jc—G+ 6, New eonstrtiction� , employees(fulland/or part-time).* have heed the sub-contractors: _ .._ ,....., m=_ a a �_.. _._ _..�t w 7. Remod.Iinb. �- t 2. I ain a sole proprietor or par[ner- act;on the:attached attached-sheet: # ship and have,no'erctple', These suh-contractors have. $. .E]DemaIii 6a worlang for foe m any capacity. workers'comp insurance, g., l g addition [No woikrrs':.copip.insurance 5. We area corporation and ids .10;❑Electrical repairs or additions a iiequ d} o�.cars have exercised:fheir 3.❑ I am ahomeowtier doiu all work right of exemption per MGL 1.1, ]Piumbmg repairs:or additiong g. myself[No workers'camp, a 152,§1(4},and have 12;:[Q Roof'repairs 1 insurance required:]t employees �1+Iu workers' ME]Omer comp.msuraaee requited.) i i rAny applicant ffinchecks-ba0l mustalso fill out the section bilow ibowing,Hi cnmp On:Policy intotmation t 33ampopVnem who.submit this afndwit'indicating they are doing all vg4t,and then:tine outside couirktod mustobmitaiiew a5davit indieating:suah $Cnnuactorsthat cheek::this box must adh6ad.anadditionalsbeetshmiugt�.name:ofthesub-contnctop and thei worlars'comp.policyinfnrm UM- I vm da employer iliat u providin;w..orkers'cmnp0sati n rnsur4We for rnl1 employees. Pelow is the policy and job site R uiforirs¢fia>7: hmrrance Company Name: t o ,O 6 k r��i f z. S U►�Ct nGC, J Eoliey .or-Self=ins...Lic.r: _ (t l (; . �iby�b-7�. Expiration Date: Job.Sita A ddress:L-.' z Lt� City/Se% v& ` A#m*s copy of tine workers'.cnmPeasa og policy declaration page(3howin the-Po3>cy number and expirsfiom date); Failnreto-sl ue eove_Iage as required.under Section ZSA afMGL c..15.2,can lead-to the.imposition:of priminal-p.nalties of a .fire up to S;1,500;OO;and/bi one-year imprisonment,a-swell as ciVil.p6nalties in.tide form of-a STOP WORK ORDER anal a fine af.up to�250,00 z-&ya : st:the violator. Be advised that a copy:of#kits siateme t mat b: arw;u ed the Li ce of Invetfions of the DIA`for insurance ..veaage ve ' ... . r l db here c ; e u»d farrlJ�hOl[PFOVIdPiL lEl�pye-is fte akde rred: P p °rt�tIe'irr Sisnatu>•e: � - i_)ate: — `� - lcolaa .only. Do not write ga this area;-1a be cam feted y city or town of rcial a: ..Permit/License _ thority(circle onel: Health 2,-Bu0dinaDegsrimeut 3.'L>tity/Town Clerk 4.glectrical Inspector 5.Plumbing Inspeet¢r rson: Phone# I it .r ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 0 1 /02/2013 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 CONTACT NAME: Mackintire Insurance Agency, Inc. AJ CON (FAX aCNo:508.366.5202 11 West Main Street E-MAIL ADDRESS: Westborough, MA 01581-1931 PRODUCER 00013793 CUSTOMER ID#: INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A: Peerless Insurance Co. 24198 Newpro Operating LLC INSURERS: Acadia Insurance Co. 26 Cedar St. INSURERC: Woburn, MA 01801 1 SURERD: INSURER E: i INSURER F: COVERAGES CERTIFICATE NUMBER: 12-13 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 PERIOD DI ON ANY CONTRACTOR 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 LIMITS LTR INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD+YYY GENERAL LIABILITY CBP 858957 12/31/2012 12/311'2013 EACH OCCURRENCE $ 1,000,000 - X COMMERCIAL GENERAL LIABILITY DAMAGE TO—RENTED PREMISES Ea occurrence $ 100,000 CLAIMS-MADE I OCCUR MED EXP(Any one person) $ S,000 A PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 i GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 i POLICY JECT LOC $ AUTOMOBILE LIABILITY BA 858417 12/31/2012 12/31/2013 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ , ALL OWNED AUTOS BODILY INJURY(Per accident) $ A X SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS (Per accidenq $ X NON OWNED AUTOS $ $ X I UMBRELLA LIAB X JOCCUR CU 858257 12/31/2012 12131/2013 EACH OCCURRENCE $ 5,000,000 A EXCESS LIAR CLAIMS-MADE AGGREGATE $ 5,000,000 -- DEDUCTIBLE $ X RETENTION $ 10,00 $ WORKERS COMP'N ATION YIN WC-20-20-003506-0 05/01/2012 05/01/2013 X ORY IMTS OER AND EMPLOYERSANY PROPRIETOR/PARTNER/EX , B OFFICER/MEMBER EXCLUDED?ECUTIVE❑ N/A E.L.EACH ACCIDENT $ 500 QQQ (Mandatory In NH) E.L.DISEASE-EA EMPLOYEd$ 500,000 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) 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 Ne pro Operating LLC Timothy Mo na h ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD Ji - Massachusefts - Departn i,6 nat of Pudic;Safety Board of Building Regulations asnd Standards C'mistr uctiun Supervisor - License: CS-096093 i THOMAS E PEACOCK 38 OAKLANO A x SEEKONK NA a y Expiration Commissioner 04/08/2014 5 + E. { a IL/t nd z Of of Consumer Affa' a Business Regulation 10 Park Plaza = Suite 5170 a Boston, AUssachusetts 02116 Home Improve ' ontrador Registration Registration: 146589 -Type: Supplement Card NOPERATING, Expiration: Q5/2013 EWPRO LLC. t TOM PEACOCK 12! 26 CEDAR ST. WOBURN,"MA 01801 Update Address and return card.Mark reason for change. Address Renewal .Employment Lost Card DPS-Cq1 to SDM-t!4/64-G101216 Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registration J464B9 Type: 10 Park Plaza-Suite 5170 4Epirat[T , Supplement Card Boston,MA 02116- ,: NE WPRO OPERA G; TOM PEACOCK ' Y, 26 CEDAR ST- WOBURN, MA 01801 Undersecretary Not valid ' out signature , r From Our Home to Yours... MA Reg#146589 , Federal ID#20-2625129 CT Reg#0605216 AMORk9 6 3.3,r,R RI'Rig#26463 Windows,Siding and More Corporate Headquarters,26 Cedar St,Woburn,MA,(P)800-342-2211 (F)781-933-9626,www.newpro.com THIS CONTRACT MADE THE day of ter 20 between a- (Hofne Owners/} (Home Phone) (Bus/C Phone) of { ✓v�f'� /Yl t �� (� (Address) l (City) (State) (zip) the"Owner"and NEWPRO Operating, LLC, "NEWPRO". The job address is a condominium. NEWPRO hereby agrees that it will for the consideration hereinafter mentioned,furnish all labor and material necessary to install the following described work at the premises located at (Job Address) (E-Mail) for proprietary use only TOTAL Additional Model TOTAL Windows Purchased NEWPRO Work 00� v-( Number Qty CASH Window Color In: Out: Sliding Glass Door !) / PRICE -Capping Color Steel Security Door ari 3(} 4rT Door Color In: C" rIP Out: a G DEPOSIT 0-0 Model Name Model Number(s) Oty Sidelites WITH Double Hung New CQnstru A0—rIJ1aiLJ,2 }� ORDER Picture Window form Door BALANCE Casement Obscure Glass -STOP PT-roM DUE AT 2 Lite 13 Lite Slider Screens ...HALF —Fl?CL INSTALL Bay/Bow Frame Please Initial: v s Roof. ❑ Soffit: ❑ Customer understands that NEWPRO®does not CASH Garden Window do any painting or staining. (ie:when removing Balance paid to installer al installation Awning or replacing interior stops or trim) Hopper NEWPRO®is not responsible for conditions or Shaped ,{ circumstances beyond its control including con- NC .f Other densation resulting from or due to pre-existing Bank completion form signed at installation GRIDS '>tU Colonial SDL Euro conditions. DESCRIBE, ORK: 4 1 II 2 . Psi¢ C rs` /P ' Pv4 e Est.Start Date: 3 Customer understands this is an"estimated date" V� t Est.Comp. Date: ) �" Willa s Inr9 ,::Customer understands all steel security doors will have a 3/4"aluminum threshold installed over existing threshold. It shall be the obligation of NEWPRO to obtain any and all permits necessary under this agreement,as the Owner's Agent. The Owners who secure their own construction-related permits,or deal with unregistered Contractors will be excluded from the guaranty fund provisions of MGLC, 142A. All Home Improvement Contractors and Subcontractors shall be registered by the Director and any inquiries about a Contractor or Subcontractor relating to a registration should be directed to: Director,Home Improvement Contractor Registration,One Ashburton PI,Room'1301,Boston,MA 02108,(617)727-8598. If the Owner is obtaining financing by way of a Retail Installment Sales Agreement,such Agreement shall include a time schedule of payments to be made under said contract and the amount of each payment stated in dollars,including all finance charges. The Retail Installment Sales Agreement shall be incorporated herein by reference. If the Owner is obtaining a revolving credit line to pay,in whole or in part,for the contract amount herein,the terms of the revolving line of credit including interest rate and payment terms,shall be clearly set out on the credit application. The portion of the credit application referencing a time schedule of payment,to be made under this contract,and the amount of each payment stated in dollars,including all finance charges,shall be incorporated herein by reference. NEWPRO represents that it carries Workmen's Compensation and Public Liability Insurance in the amount of$100,000-$300,000. If the Owner refuses to permit NEWPRO to proceed with the work herein,or in the event of any breach of the Owner of this agreement,for any reason whatsoever shall cause the owner to pay NEWPRO a sum of money equal to thirty-three and one-third percent of the price agreed to be paid,as fixed, liquidated and ascertained damages,and not as a penalty,without further proof of loss or damage. NEWPRO shall not be held liable in damages for delays in the performance of this contract due to causes beyond its reasonable control. Owner warrants that he is the owner of the property on which the work is to be performed or that he is otherwise authorized on behalf of the owners to enter into this agreement. ' This contract represents`tfie'entireagreement between Owner.and NEWPRO and cannot be changed except in writing signed by both the Owner and NEWPRO. You are entitled to a copy of the Contract gat the time ybu sign. Keep it to protect your legal rights. We,the aforesaid owners,certify that immediately'after the signing of the aforesaid agreemeAt, a copy was'furnished to Us. You may cancel this agreement if it has been signed by a party thereto at a place other than an address of the seller,which may be his main office, or branch thereof, provided you notify seller;in writing at his main office or branch by ordinary mail posted, by telegram sent or by delivery, not later than midnight of the third business day following the signing of this agreement. (Saturday is a legal business day). See the attached notice of cancellation form for an explanation of this right. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. V�Thewner has seen"sample"warranties that will be provided by NEWPRO upon installation. Sample warranties provided to Owner. IN WITNESS WHEREOF,the parties have hereunto signed their names this day of' ""�"{:- 20 t +rrt r'G EIN# SignedI✓t- {f,�s" rj-marl- MarketingKepresentative Printed Name Owner Accepted: NEWPRO per atin g,LL By s Signed Owner CORPORATE OFFICE WARWICK BRANCH OFFICE 26 Cedar St 24 Minnesota Ave Woburn,MA 01801 Warwick,RI 02888 (P)800-242-9974(From NE) (P)800-356-3312(From NE) (F)781-933-0717 (F)401-732-1371 WHITE: Branch Copy YELLOW: Customer's Copy PINK: File Copy GOLD: Finance Copy US-15 R0508 r~ TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 0 Parcel Application :00 0/,� V(® 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 Village )IV -X Owner Address Telephone, Permit Request r'-1 - rare c� c���dl�g d>".�.� �., A, c-44 c 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, 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. oom Count (not including baths): existing new First Floor Room Count r HE:"4.4 pe and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing w*@-O-' /coal stove: U_-__''es ❑ No Detached garage: ❑existing ❑ new size Pool: ❑ existing ❑ new size _ Bar existing❑ nely sizeCa Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: :�3 Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ roe Commercial ❑Yes ❑ No If yes, site plan review # CCY rn Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Mike McCarthy Construction Telephone Number IFU g 52 Address West Dennis, MA 02670 License # �_Cei(508)�280-6NL �`r--CSL-58633: IC-193 Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE VdS-)I2 FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE AD OWNER L +� Aw ! J r .s: DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING t DATE CLOSED OUT ASSOCIATION PLAN NO. yA;r('3 f` f' R. The Commonwealth.of Massachusetts Departtrnent of Industrial Acciderrft Office ofInvestigations .. 600 Washington Street Boston,MA 02111 wwru mass.gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Plectricians/Plumbers Applicant Information Please Print Legibly Name (Business/oro nizatioVIndividuat): McCarthy Construction Address: West Dennis,MA 02670 City/State zip.- Phone#: F2. e you an employer? Check the appropriate box: 4.' I am a general contractor and I Type of project(required): . I am a ess�loyer with ❑ g � ployees(full and/or part-time).* have hired the sub contractors 6 ❑New constructionI 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 forme in any capacity. employees and have workers'. [No workers'Comp.insurance comp.insnrance.t 9. ❑Building addition 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 r�EU M iamrance regidred.]t c. 152, §1(4), and we have no 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 aE work and then hire outside ceatractors must submit a new afndavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and stake whether or not those entities have employees If�c sob-contractors have emploYoes they must provide their workers'cPolicynumber. �• I am an employer that isproviding workers'compensation insurance for my employees. Below is the policy andjob site information. Insurance Company Name: Policy#or Self-ins.Lic.4- Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers compensation policy declaration a e sh P g ( o�g 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 tine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the fours of a STOP WORK ORDER and a tine 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 certi gins and penalties of perjury that the information provided above is true and correcf ' si tore: Phone#: C Official use only. Do not write in this area, to be completed by city or town official City or Town: PermitUcense# "Issuing An, (circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: , ' OWNER AUTHORIZATION FORM (Owner's Name) owner of the property located at 72 1 (Property Addres � ej 4t4e O� 6r14 ZZ (Property Address) hereby authorize (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. Jj Owner's Sigl9ture til3l�r Date + Office of Consumer Affairs and Business Regulation 10 Park Plaza Suite 5110 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 169393 Type: Individual Expiration: 6/16/2013 Tr# 213517 MICHAEL MCCARTHY MICHAEL MCCARTHY . - WEST DENNIS, MA 02670 ;Fn a t Update Address and return card.Mark reason for change. -- Address Ej Renewal Employment F Lost Card DPS-CA1 0 5OM-04/04-G101216' ✓/ze �ay"�"°'Zu`e"/� o� ��a°°ac/��°eCt License or re istration valid for individul use only \ Office of Consumer Affairs&Business Regulation g y HOME IMPROVEMENT CONTRACTOR before-the expiration date. If found return to: Registration ,_s 1;69393. Type: Office of Consumer Affairs and Business Regulation Expiration 6162013 Individual 10 Park Plaza-Suite 5170 Boston,MA 02116 MI AEL MCCARTHY < _ . MICHAEL MCCARTHY- - . . L z 6 RANGLEY LN. ..rp YH3 p SOUTH DENNIS, MA 02660,= Undersecretary Ydtvalid without signature Massachusetts- Department of Public SJON Board of Building Regulations and Standai;dti Construction Supervisor License i License: CS 513633 r, Restricted to: 00 `:{ K. ` W s MICHAEL J MCCARTHY' F • PO BOX 52 c W DENNIS, MA 02670 i f i _b Town of Barnstable FF it: 116 0 0 Y Regulatory Services : ��Zo�l/ �°FTHe r°tyy Thomas F. Geiler, Director P Building Division 3,s/ BARNSTABLE, ' Tom Perry, Building Commissioner y mass. moo, 1639• a 200 Main Street, Hyannis, MA 02601 TfD MAC www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-b230 TOWN OF BARNSTABLF SOLID FUEL STOVE PERMIT Owner: is Phone: 0 Install at: - 1Z z t"A }r Village: �!� „s � �/4 �f a 4 Uzi Map/Parcel: Date:.: � � Stov A.r-i; sed B. Type: �adian� irculatinc, C. Manufacturer: t Lab z�. - 3 . No. D. Model No.: lam, , t✓>,. - Chi mn A. t e existing (If existing, please note date of last cleaning) C-) B. Flue Size l C. Are other appliances attached to Flue? A D. Pre-fab Type and Manufacturer E. Masonry: Lined/Unlined e-r Hearth A. Materials: B. Sub Floor Construction: 'p Installer Name: ' ZZ Address: Phone: 'Ti�6 `2 7 Location of Installation: A-t?z / 4a, H.I.0 Registration # /S-<g5q I Construction Supervisor# G i i OR check_Homeowner Installing, no lice se required APPLICANTS SIGNATURE \, v '--' APPROVED BY: .� Please make checks payable to the Town of Barnstable *This constitutes an of stove permit after inspection, photographed, and approved by the Building Inspector r y� a , The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations _ a 600 Washington Street Boston,MA OZIII wyvw.mass.gov/dia Workers`Compensation Insurance Affidavit: Builders/Coiltractors/Electricians/Plumbers A lic ant.Information .Please Print Le 'bl N3Il1e(Basiaess/Organ zz ion/Individual): . ..- -'c; 5 y, Address: C, J City/State/Zip:_Z �;> ti Z u'{` ( Phone.#: .C� Are,,you an employer? Check the appropriate box: .Type of project(required):. 1.'o I am a employer with �_ 4. I am a general contractor and I 6. ❑New construction . employees (full and/or part-time).* have hied the sub-contractors 2. I am a'sole proprietor or partner- Lsted on the'attached sheet . 7. ❑Remodeling b-contractors have ' ship and have no employees These su 8. ❑Demolition vorkin for me in an capacity. employees and have workers' g Y 9. U Building addition [No workers' comp. insurance comp. insurance,$ required.] 5. We are a corporation and its 10.❑Electricalrepairs or additions :� ' . officers have exercised their 11. Plumbing re 3.El I am a homeowner doing all work. . • S airs p ' or additions ' myself, [No workers' comp. right of exemption per MGL 12,❑Roof repairs insurance required.] c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp, insurance required.] *fury applicant that checks box Tl must also fill out the section below showing heir workers'compensation policy information. t Homeowners.who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew amdavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the$ub-contractors and state whether ornot those entities have employees. Ifthe sub-contractors have employees,they must provide their workers'comp.polity 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: j i 6 G/ ls �j�°" l'•L' Policy m or Self-ins.Lic.#: k✓G Z- 3 15 ' l/7,7! 1 0 3 0 Fxpii ation Date: Job Site Address: t' � City/State/Zip:11` r.,s lS Z , ��� :•ii?6r, 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$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ido hereby certify u/ the pains•andpenalties ofperjury that the information provided dbov ,is true and correct. Signature: "� Date: ����� Phone#: official use only. Do rot write in this area, to be completed by city or town official. City or Town: ' P ermitfLicense# Issuing Authority(circle one): ' • , .1,Board of Health 2,Building Department 3. City/Town Clerk 4.Electrical Inspector S,Plumbing Inspector 6, Other `: ✓iie vrrrrvizo�uuvcusn ay✓vuaa�acnu4P,ua _- Office of Consumer Affairs&Business Regulation License or registration valid)for individul use only - HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to- Office of Consumer Affairs and Business Regulation Reg istrationL;L_1,58588 10 Park Plaza-Suite 5170 A Expiratiord �2t1 f2012 Tr# 291750 Boston MA 02116 TYPe, MASS BUILDINGISYS�T�EMS=: °r STEPHEN BOBOtA= ,t3:- 24 ST.FARNCIS CIRCLET -a-x9G�_ "� HYANNIS,MA 0260T' P=i'"` Undersecretary Not valid without signature iils2dt�ittt${4 I)�:'I'ti'tld9Cd7t.()l �ll:l}IdL�.lt. �1! s" ts►►,trt1 ref RW1114 g Rcgulmki► .i'nd Statntl.i►cl r ConsflbUctdonSupervisor License,; Wcense CS 58987 i R,»� lted to: 00 STEPHE�N E BOBOLA + 24 c E FRRNClS CI' HYANAiiB, MA 02601 EX,t iatron: 2/4/2012' Try, .'588'2 i I_ i ✓ne var,�n�a,nuuecuch oy✓vUZ�cktCsuiq¢� -- Office of Consumer Affairs&Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation Registration.::J 8588 10 Park Plaza-Suite 5170 Ex iratidn12�`k/2-012 Tr# 291750 Boston,MA 02116 p r TYPe`;t;� Pa#ne shrpl"��i MASS BUILDING SYSTEMS=- STEPHEN BOB LA, fi- ' �--" 24 ST.FARNCIS CIRCL�1���/� HYANNIS,MA 02601 Undersecretary Not valid without signature Restricted to:.'00 f.- 0U r Vnrestricted 1 21+amily Homes 1� • . Failure to possess a current edition of the Mas.,* • �-vetts State Buildi'iig Code- `� s is cause for revocation of this license. , 'Refer to:. *WW.Masi Gov/DPS k Aco® CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYW) `.� 10 19 2010 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 BRYDEN &SULLIVAN INS CONTACT NAME: 88 FALMOUTH RD PHONE • 508 775-6060 A/c No): HYANNIS, MA 02601 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Liberty Mutual Group INSURED CAROLYN BOBOLA&STEVE BOBOLA INSURER B: DBA MASS BUILDING SYSTEMS INSURERC: 24 SAINT FRANCIS CIRCLE HYANNIS MA02601 INSURERD: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 8568507 REV!S!CN 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. ILTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MMLDDYIYYYY MMIDDIYYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) AUTOS 8 AUTOS $ NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident Is I Is UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION WC2-31 S-317211-030 10/3/2010 1002011 WC STATUL,.,T CLR AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE[�7� E.L.EACH ACCIDENT $ 500000 OFFICERIMEMBER EXCLUDED? I Y I N I A 11 (Mandatory in NH) E.L.DISEASE-EA EMPLUYEE $ 50000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 5 500000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required) NO PARTNERS ARE COVERED BY THE WORKERS COMPENSATION POLICY Workers Compensation Insurance:Part One of the policy applies only to the Workers'Compensation Laws of the State of MA. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TOWN OF YARMOUTH THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ATTN: BUILDING INSPECTOR ACCORDANCE WITH THE POLICY PROVISIONS. 1146 RTE 28 SOUTH YARMOUTH MA 02664 AUTHORIZED REPRESENTATIVE n Jeff Eldridge 0 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD CERT NO.: 8569507 CLIENT CODE: 1306875 Deb Derochemont 10/19/2010 7:37:40 AM Page 1 of 1 Y � V 1 �1HE r Town of Barnstable Regulatory Services vBARNSTABLE ; Thomas F. Geiler,Director fD �A Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.b arnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section TT 11 US!-- A �D U*lder I, 5 e_ as Owner of the subject property hereby authorize -. to act on my behalf, mass t d t-rS , in all matters relative,to work authorized by this building permit application for. A oato© 1 (Address of J ) Signa e of Owner Date Pant N#ae If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. - T ' li f r. k � . 4 ti - � - tt t a l j a .» r � . 3Kee - r , Town of BarnstablePermit: -THErp Regulatory ervlP&'NSTABLE ate: P o,� Thomas F.G? d �.`� 9: 21 ee: �S O sMMMBLE, : Building Division 9 MASS. 1639. Tom Perry, Building Commissioner a 200 Main Street Hyann;;'MbF( 691 f. tU Office: 508-862-4038 Fax: 508-790-6230 TOWN OF BARNSTABLE SOLID FUEL STOVE PERMIT Owner: °1 'LI I �� I Phone: (5-D S) 9 a 9-3+i3 Install at: Villager n n 1 S Map/Parcel: Date: 1 - a] -O 3 Stove A. New/ sed B. Type: ad ant Circulating C. Manufacturer: Lab. No. D. Model No.: Chimney A. Ne Exi in (If existing,please note date of last cleaning) NoJ)Cx bee QOD-. B. Flue Size C. Are other appliances attached to Flue? D. Pre-fab Type and Manufacturer E. Masonry: Lined/Unlined Hearth A. Materials: b r i c B. Sub Floor Construction: Installer Name: Address: Phone: Location of Installation: APPROVED BY: `v Q Please make checks payable to the Town of Barnstable *This constitutes an official stove permit after inspection,photographed, and approved by the Building Inspector Q:forms:stove Rev 122801 j. " �, t ,ti �- .. �� �,�-�Y-`'� ��Y..� .F.f ,. .!'�y ..9 { _ � !1ti ■ .�..�.. �, � � � � .. �. _ _�` f f a;� � �i 6. � ! ' � ,. �. .._ w � , _ '� # i! � r �! � � `,�� � � � . _ �_ � : � ; - .-_ �; f � , ���' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION f Map Parcel Application #W,)z Health Division Date IssuedC) Conservation DivisionApplication F Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address 3 2, 11 e l 0 Village�n n S Owner i mvn & Address Telephone a08) -1 q 0 -3'fi 3 Permit Request C - Square feet: 1 st floor: existing proposed 2nd floor: existing pro ed Total new Zoning District Flood Plain Groundwater O rlay Project Valuation Construction Type Lot Size Grandfathered: ❑Yes o If yes, attach supporting documentation. Dwelling Type: Single Family , ❑ Two Family ❑ Multi- mily (# units) Age of Existing Structure Historic House: es ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ her Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft)l ` Number of Baths: Full: existing ne Half: existing - news r Number of Bedrooms: exis • g —new ': { Total Room Count (not including baths): e sting new_ First Floor Room Count F2 Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑Other_ Central Air: ❑Yes ❑ No Fir places: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑existing new size—Pool: ❑ existing ❑ new size _ Barn: ❑existing ❑ new size_ Attached garage: ❑ existin 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 - 14 Telephone Number 4 ) 3 Address License # N 14 i I Home Improvement Contractor# k 1,4 Worker's Compensation # Nift ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO N 14 SIGNATURE - DATE -1 J X7 J I.O t FOR OFFICIAL USE ONLY y � r APPLICATION# t t' DATE ISSUED ).t71, MAP./PARCEL NO.--: _ —ADDRESS_ h VILLAGE s' OWNER r i t r DATE OF INSPECTION: < h�,fOUNDATION y FRAME INSULATION: t FIREPLACE ELECTRICAL: ROUGH FINAL ,t ' PLUMBING: ROUGH FINAL ..! . GAS ,i�i_ ROUGH R , .., £ FINAL f a SF, FfNALBUtLDING `=`: �� t DATE'CLOSED OUT _u 1 ASSOCIATION PLAN NO. 1 l Tlt.e Commonwealth of Massachusetts �, ---- Department of Industrial Accidents ' Office of Investigations 600 Washington Street t� Boston, MA 02111 www.m.ass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Informatio-i Please Pririt Legibly L Name (Business/Organization/Individual); �I - t :5-5 Address: City/State/Zip: I Phone M o 34 3 Are you an employer? heck the appropriate box: Type of project(required): 1.❑ I am a employer with 4. [] I am a general contractor and I * have hired the sub-contractors., 6. ❑New construction employees(fti11 and/or part-time). --listed on the attached sheet. 7.---._..._.__...._-..Remod e.. _....g .._ . 2.❑ I am a sole proprietor.or partner- ❑ lin ship and have no employees These sub-contractors have g, ❑ Demolition, working for me in any capacity. uranceemployees and have workers' 9 ❑ Building addition comp. ins . No workers comp. insurance 10.0 Electrical repairs or additions required:] 5. ❑ We are a corporation and its 3. I am a bomeowner: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 13 ❑ Other employees. [No workers' comp. insurance required.] *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they arc 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: Policy#or Self-ins. Lic.M Expiration Date: Job Site Address: City/State/Zip: 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 pairs and penalties ofperiury that the information provided above is true and correct. Signature: Date: 0 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 Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: f xA oF tr+r r , Town of Barnstable o Regulatory Services Thomas F. Geiler,Director swtixsres t re, Mwss. �b E 16s� ,�� Building Division Pro►,w{" Tom Perry,Building Commissioner 200 Main.Street, Hyannis,lAA 02601, •vs ww.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMTTION Please Print DATE: 1IoZ1 I �o JOB LOCATION: J OC Lti IG' ' s 02*O 1 'number street village "HOMEOWNER!':- rl� u +bn t 5 SG 9'0 - 3 °f i 5 FS&�2- 53 `7-0 name home phone# work phone# CURRENT MAILING ADDRESS: ,L•- 11 c /town stater 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. DEFINmON of HONMON'VNER 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 constrgcts 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'Buildiiag Department minimum inspection procedures and requirements and that he/sbe will cornply with said procedures and requirements. Signati.rr f 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 scction.(Scction ID9.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a persons)for hire to do such work,that such Homeowner shall act as supervisor." 14-any homeowners who use this exemption are unaware that they are assuring the responsibilities of a supervisor(see Appendix Q, Rules&Rcgvlations for Licensing Construction Supervisor,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 homcowncr certify that he/she understands the responsibilities of a.Supmisor. 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'certiftcation for use in your community. Q:f omits:h o m ccx cmp t THE rti Town of Barnstable Regulatory Services f f HARN f f K&qELF- . Thomas F. Geiler,Director eo.19. 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 rt-Y e Owner Must ust Complete and Sign This Section If_ Using A Builder as Owner of the subject property hereby authorize to act on my behalf, m all matters relative to work authorized by this building permit application for: (Address of 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. Q:FO RMS:O WNER.PEWISSION