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HomeMy WebLinkAbout0351 MEGAN ROAD r2c� -- - - - - — — -- - - -- -- - -- --- . Town of Barnstable Building Post,This Card.,So:That rt•is Visible From the Street ApprouedPlans Must be Retained onJob and'this Card Must be Kept +- WAS". ' Posted Until=Final InspectwnHas BeenMadey Y �� NPermit Where a Certificate�of Occupancy�s�Required,such Building shall Not be Occupied until a Final Inspection has been made ~ . , . ., .... ..a� Permit No. B-18-857 Applicant Name: O'NEILL, DANIEL L&ALLISON J Approvals - Date Issued` 03/27/2018 Current Use: Structure Permit Type:. Building-Siding/Windows/Roof/Doors Expiration Date: 09/27/2018 Foundation: Location: 351 MEGAN ROAD, HYANNIS Map/Lot 290-127 Zoning District: RB Sheathing: Owner on Record: O'NEILL,DANIEL L&ALLISON J x Contractor Name Framing: 1 Address: 351 MEGA_ N ROAD i Contractor'License 2 HYANNIS, MA 02601 �; Est Project Cost: $5,500.00 Chimney : P rmit Fee' $35.00 Description: Re-Side _ { fi Replacement Windows U-Value.28(8) Replaceme Insulation: ntDoors(2). Flee Paid S 35.00 k Date 3/27/2018 Final: Project Review Req: Plumbing/Gas Rough Plumbing: Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within simonths after:issuance. All work authorized by this permit shall conform to the approved application rand the approved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zo6ing1,6y laws and codes. Final Gas: This permit shall be displayed in a location clearly visible from access street orroad and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. Electrical The Certificate of Occupancy will not be issued until all applicable signatures bey the Building and Fire3O, iicials�a a provided o th s permit. Minimum of Five Call inspections Required for All Construction Work: Service: 1.Foundation or Footing Rough: 2.Sheathing Inspection _ ' ' ., „ , �, - 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as.set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT I Town of Barnstabl 4l, *Pert ' �J Building Department "Tare onthsfromissue ate sattxsTnei.e, : Brian Florence,CBO b ,t � Building Commissioner `~J sp Mpr°i 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number ,/� Lr /,, �J Property Address .a,�r ./� e.., V tc� I��j c N h, S /mil A 0.Z Go , esidential Value of Work$ 5 Sa. 0.0 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address �G-n, r Contractor's Namepc.1 C �Q t/ Telephone Number SG Z:?' 3 7 "3 Home Improvement Contractor License#(if applicable)/G.q ��. Email: CG//D..'/"�� S^c,��.C. Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance y0 MA�� Check one: / ^I ❑ I am a sole proprietor ����� Dd I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to 0-1 S�� ��Q�✓ ❑R -roof(hurricane nailed)(not stripping. Going over existing layers of roof) Re-side 11 Q 8 replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: ;Z *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. SIGNATURE: C:\Users\deco)l ik\AppData\Local\Microsoft\Windows\1NetCache\Content.Outlook\9NNOKXY W\RESIDENTILONLYEXPRES S.doc 09/26/17 I i :f Tyre Commonwealth ofMarssackusetts - Deparanent o_f Industrial Accidents _. _. Office of Im,esfigations y �-y -� 600 Washington Street Boston,M4 02111 *Prig:max&gov1dia. Workets' CoffipensMion Insurance Affidavit:.BnildersICentractorsJ ,a�ctiticiansll'lambers Applicant Information Please Print Legibly.. Name(Busimnorgan za y tronllruhvidnai): ��. .0;c&�... Address: City/State/Zip. Phone 47 So Ate you an employer?Check the,appropriate boa -Type of project(required): 1 ❑ I am a employer with 4. ❑ I am a:general contractor and 1 6- ❑New construction employees(full andlor part-time)_* have bared the sub-contractors 2 ❑.I am a sole proprietor or partner- listed on the attached sheet 7- [modeling ship and have no employees Tie sub-contractors have g- ❑Demolition . working forme in any capacity. ..employees anel have wo mrs' 9- Buildingaddition. [No workers'comp-insurance comp-m ��s, , I ❑ r j 5 ❑ due are a corporation and its 10:❑Electrical repairs or additions 3: am a homeowner doing all work.. officers have exercised their 11-❑Plumbing repairs or additions if o workers' right of exemption per MGL myself 4,152 1 andviwe have no 12-❑Itoofrepairs insurance required-]-t c. � ( ), 13-❑Other employees- workers' o mP y - comp-insuranoe required-]. -Any applicant that checks bog#1 must also 5ll out the section below showing their workeis'compensationpolicy information t Homeowners who submit this affidavit indicating they are doing all work and then Mine outside contractors Wrest submit a new affidavit indicating,sock.. :.' 4Contmctors that check this boa must attached ffi additional sheet showing the name of the sub-couftxtors sad state whff&u or not those entities hwe employees. Ifthe sub-contractors have employees,they most provide their workers'camp.policy number- I am an employer that is prmRding workers'coaWnsadfon insatrtance for ntv employees. Below is thepolicy rand job.site informa on, Insurance Company Name: Policy 4 or Self-ins-Lie-# Expiration Date: Job Site Address: CiWStatelZip: 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 2.5A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500-00.andlor 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 certi 6qjnder the pains and penalties of pediuy that the infornnrtion provided above is date and ccorrect lure: Date: ✓' 6 �8 Phone 4: i Official sae only. Do not twite in dais arena,to be completed by city or town official. City or Town: PermitUcense# Issuing Authority(circle one). 1.Board of Health 2.Building Department 3.Cityfrown.Clerk.4.Electrical Inspector 5.Plumbing Inspector 6.{Iher Contact Person: Phone#. 6 Town of Barnstable Building Department Brian Florence,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 BAMSTABM v MAss. www.town.barnstable.ma.us i639• ♦0 'ED�A Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION 3 -.2 �j ^ 16 Please Print DATE: m JOB LOCATION: ✓V('�/ '� '—` 14 6~A 40.5 number / / street ? village ••HOMEOWNER":___Pr—y1 I L V �Lt 1 A_ home phone# work phone# CURRENT MAILING ADDRESS: /''( ��.a"'� r g city/t wn 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 pro es 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 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands.the responsibilities of a Supervisor. On the last page this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. C:\Users\decollik\AppData\Local\Microsoft\Windows\INetCache\Content.Outlook\9NNOKXY W\RESIDENTILONLYEXPRESS.doc 09/26/17 YOU WISH TO OPEN A BUSINESS? For Your Information: Business certificates (cost$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 permission 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, 1st FI., 367 Main St., Hyannis, MA 02601. (Town Hall) and get the Business Certificate that is required by law. DATE: Ma�Z/_ Fill in please: APPLICANT'S YOUR NAME/S: BUSINESS YOUR HOME ADDRESS: ir: '+SI.1^tii:a:;r wttFj j;,• ,•,y�r_r;' TELEPHONE # Home Telephone Number _737 3�.1 NAME OF CORPORATION: NAME OF-NEW BUSINESS L. D J) C,,tjoeh t.,,r TYPE OF BUSINESS C 4r IS THIS A HOME OCCUPATION?___X,_YES N ADDRESS OF BUSINESS. . 5 4 14 —hc MAP/PARCEL NUMBER [Assessing] When starting a new business there are several things you m.ust do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. — (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. '1. BUILDING COMMISSIONE OFFICE MUST COMPLY WITH H S.ME OCLUR TI N This individual has bee of ed of anjper uirements that pertain to this type of business. RULES AND REG COMPLY MAY RESULT IN FINES. nut rized S' at re** COMMEN S: 2. BOARD OF HEALTH that ei�tain to this e of business. been informed of the permit requirements h type This individual has p q P , Authorized Signature** COMMENTS: 3. CONSUMER AFFAI (LICENSING AU ORITY) This individual i ed ing requirements that pertain to this.type of`business. Sign COMMENTS: Town of Barnstable THE Regulatory Services p Tp� c Richard V. Scali,Director `* a�Bivsr�Bt.B. Building Division MASS. Paul Roma,Building Commissioner sb3q.a�0� 200 Main Street,Hyannis,MA 02601 www.town.b arnstable.ma.us Office: 508-862-4038 Fax:. 508-790-6230 Approved: Fee: Permit#: — HOME OCCUPATION REGISTRATION Date: Name: �4-,i / Q�Ne r l Phone#: 5 G$— 3 -3 7/ k Address: S 2c•-. Village: Name of Bus in`ess: �a� �• ©N.er l� C�rpti'i�-�y Type of Business: CAS t 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,subj ect 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: • carried The activity is 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 or other 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 jand agree with the above restrictions for my home occupation I am registering. I Applicant., / Date: Homeoc,doc Rev.06/20/16 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION MapParcel n # pp ca o 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 A ress Village h Owner + �i( I Address Telephone Permit Request I w aw l�� f � D "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 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 Q No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION UU Yam_DDER OR HOMEOWNER) Name Telephone Number Addres License# U I U Home Improvement Contractor# S b Email Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING F OM THIS PROJE T WILL BE TAKEN TO SIGNATURE DATE 4 E . FOR OFFICIAL USE ONLY eAPPLICATION# DATE ISSUED MAP/PARCELNO. ADDRESS VILLAGE t OWNER DATE OF INSPECTION: FOUNDATION FRAME n INSULATION FIREPLACE r ELECTRICAL: ROUGH FINAL ,4 PLUMBING: ROUGH FINAL GAS: ROUGH FINAL j FINAL BUILDING D#T,B;�LOSED OUT ASSQ-0- 4TION PLAN NO. Massachusetts -Depaftmi"t of Public Safety $oard of Building Regula#fons jattd Standards Construction Supervisor License: CS-100988 « , HENRY E CASSIDY' r 8 SHED ROW WEST YARMOVFH JV- 2— / cJ � Y Expiration Commissioner 11/11/2015 s 4 Office of Consumer Affairs and Business Regulation - ,;` 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration ZH3 Registration: 153567 } Type: Private Corporation 1'y& Expiration: 12/15/2014 Tr# 233831 { CAPE COD INSULATION, INC I 4 { ; HENRY CASSIDY 18 REARDON CIRCLE '' SO. YARMOUTH, MA 02664 _ >,'Update Address and return card.Mark reason for change. SCA t Co 20M-05/11 Address Renewal Employment Lost Card V`LL' (JP�/'/'(//7'LO��GL/16CGUI2 O�C-���LddQ.Gl'LCC'JU'r.C� . _ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only O'VOME IMPROVEMENT CONTRACTORbefore the expiration date. If found return to:gistration: ;1'63567 Type: Office of Consumer Affairs and Business Regulationpiration:;... 12%1;5/201,4 Private Corporatiesi 10 Park Plaza-Suite 5170 { 1 � Boston,MA 02116 CAPE COD INSULATION HENRY CASSIDY , 18 REARDON CIRCLE;:•. ;= ' g ,z SO.YARMOUTH, MA 02664- Undersecretary of val witho t sifnat re I + { t F The Camcnsarr)uea!!h ofl'llassachresetls Ml Department of Industrial Accidents QYiee of Investigations 600 Washington Street Boston, ILIA 02111 w�vw,rr�cxss.gov/dia Workers' ( otxaperss�ltYou1 YUsurilace Affidavit: But.ilders/Contratctors[Elect ritciansipitl><libers 4 i i1.1�':trYt �tY$tYY"1.1ll:tI�iQYttir Melt e Print l.,e ibly ;i;;itiic ll�u,uic�si�?r�;ulticutio[t/lndividu�t! �' / ��Gf .. _� � Phone #: u� �,_ t 41-- I Lrr you Uu etxtplayei ,? c1yeck the appropriate box: Type of project (required): A r.tuploycr with. 2 4. [] 1 ant a general contractor and 1 `npluycc.s (hill '1114,1 e part-ti,.rne).* have hired the sub-conractors 6. ❑ Now cotistxuctioll ant a sole proprietor or pamlcr- listed on the attached sheet, 7. [] Reniodelibg :,hip a,ad have ao cluployces These sub-contractors have g. (� pernolition. wurkuig for the irx dzy capacity. employees and have-workers' _[No workcrx' comp. insurance comp. insurances 9, Q Building addition. n:ytiir�d:] 5. We are a corporation and its 10,❑ Electrical repairs or additions 1 am a homeowner don' 19 all work officers have exercised their ;-1,.t„❑ Plumbing repairs or additions Mysclr. ['No workers'.comp. right of exemption per MGL _ I11:1Ua`anCC Y4""lt lala�Gd,] t '- - � C, 152, §1(=l), and we have no 12,❑ Roof repairs F,.(J I :uu a hcuricowucr actin as a 13, Other 5,.• // B employees. (No worker' � .�---:-.,:..�.��._..,�..—_.._.. ;cricral contractor(refer to #-4) __.--- comp.insurance required-) '�aty�p{tltcwt dirt chccics box#-1 musi alyu till out the section below showing their wocim'cumpcnsatioidj aiicy intarrnatiou. t tlu,n"Jwucrs whu subrtiit this atfirlavit indicating they arc doing all wort;and then hire outside contractors must submit a new utlittavir iudkatirtg such. ilutt check-ttiis box ra"i attached an w1d.itioaul sheet showing the aurae of the sub cuamuton and%aw whettl_or not those ealitica have sub-cunrracturs have crnployccs, they must provide their wurknn'Gump.policy number. l,cur rxra rmplayer that is pea vitlirYg workers'cumtpertsrxtion insurtince for my entployeex Velow is the policy urid job site iitju�nrulrurc, 1t17uian�c l;wupivay N:i.q�e: ��%/✓r�/�L ���/,I�/�/U . l'ult�y rr or Self-ills. Lic. #: Expiration Date: 1 to In a�l c dre s: — (� 6LI -- ----- Ctty/SateJZip: ' _V1,(Lj ►V I �circti a cups of the workers' cot pensa di)a polity declaration page(showing the policy uttawib r aund expirutlou date). 1 atitu", w xcCtuc-coverage as rt qt led under,Section 25A of MGL c. 152 can lead to tha impositiotY of Grulauat►1 penalties of a tinc up tr,31,5W.O0 and/or one-year irnprisonrnent, as well as civil penalties in the form of a STOP WORK ORDER and a tineA. . r up to S250.00 a clay against,the violator. BC advised that a copy of this statement may be forwarded to the Office of !nvcstiS,riow of the DIA for uaJuzallce coverage verification, (do hereby certify ,tnder th,c_trlr jbnd penaltieat of perjury that the information provided a- ve is titre and correr4 oldiciai urc wtly. Do not write in eiriis area, to be completed by city or town officiuL i,'ity Of ]'()rein; - -— � Perruit/Llcense# issuing,luthoriry (rirrle oae): - 1. livarJ of healih 2, Builtllug Dcpaartaieat 3. City/ToWru Clerk 4. Electrical Inspector S. P1tj nib Ing inspector D.Other t.'uufut r fersoaa: Phone ; rs CAPECOD-27 CVANGELDER DIYYYY) E(MMID CERTIFICATE OF LIABILITY INSURANCE DATE 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). CONTACT PRODUCER NAME, Cape Cod Commercial Rogers&Gray Insurance Agency,Inc. PHONE - FAX 816-2156 434 Rte 134 A/C No.Extl: (AIC,No):(877_ ) South Dennis,MA 02660 ADDRIESS: INSURER(S)AFFORDING COVERAGE NAIC N INSURER A:Peerless Insurance Company INSURED INSURER B:COMMERCE INSURANCE COMPANY Cape Cod Insulation Inc INSURER C:Evanston Insurance Company 18 Reardon Circle INSURERD:ATLANTIC CHARTER INSURANCE GROUP South Yarmouth,MA 02664 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 ADDL UBR POLICY EFF POLICY EXP LIMITS LTR TYPE OF INSURANCE POLICY NUMBER MMIDDIWYY MMIDD/YYYY A X `COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 r l ®OCCUR PREMISES CBP8263063 04/0112014 04/01/2015 -DTWVG�TD-RFNTEU_ 100,00 J CLAIMS-MADE Ea occurrence) $ MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,00 iGEN'L AGGREGATE LIMIT APPLIES PER: . GENERAL AGGREGATE $ 2,000,00 X POLICY I PRO-JEC LOC PRODUCTS-COMP/OP AGG $ 2,000,00 i $ i OTHER: AUTOMOBILE LIABILITY _ EOa accc deDISINGLE LIMIT $ � . B —_i ANY AUTO 14MMBCKVMK 04/01/2014 04/01/2015 BODILY INJURY(Per person) $ I ALL OWNED y SCHEDULED BODILY INJURY(Per accident) $ 1,000,00 f I AUTOS AUTOS NON-OWNEDI PROPERTY DAMAGE $ X I HIRED AUTOS X�AUTOS Per accident I X I UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,00 I C EXCESS LIAR CLAIMS-MADE R/O XONJ453512 04/01/2014 04/01/2015 AGGREGATE $ i _ DED X 11 RETENTION$ 10,000 Aggregate $ 1,000,00 ER WORKERS COMPENSATION STATUTE FERH AND EMPLOYERS'LIABILITY D ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N WCA00525904 06/30/2013 06/30/2014 E.L.EACH ACCIDENT $ 1,000,00 I OFFICER/MEMBER EXCLUDED? 7N NIA — - (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,00 If yes,tlescnbe under E.L.DISEASE-POLICY LIMIT $ 1,000,U0 DESCRIPTION OF OPERATIONS below I I I i DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers Compensation includes Officers or Proprietors. Additional Insured status is provided under the General Liability and Auto Liability when required by written contract or agreement with the Certificate Holder. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE EVIDENCE OF INSURANCE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD i Wim� mass save PERMIT AUTHORIZATION FORM owner of the property located at: (Owner's Name,printed) QJ3e a.. G•.n�S (Property Street Address) (CitylFown) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation. and/or weatherization work on my property. Owners Signature Date FOR CSG OFFICE USE ONLY Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: CAPE CD D 7:rA5&CLATIa✓t -. Participating Contractor Date Rev. 12132011. Qz�?c2 3o �il+e Town of Barnstable *Permit# ^� Expires 6 months om issue date Regulatory Services Fee s� -- 1ARPMABIM � Thomas F.Geiler,Director X-PRESS .PERMIT MASS �m Building Division Tom Perry,CBO, Building Commissioner. NOV 2 1 2012 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 . TOWNIGF OAPNWABLE EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number® � Prop rty AddressA J �'-t- [Residential Value of Work• I .W Minimum fee of 35.00 for work under $ de $6000.00 Owner's Name&Address Se l r n. C' l��l ( ✓ "1 �� Contractor's Name An/el/ - ()U t 1 I Telephone Number �7 o U Home Improvement Contractor License#(if applicable) 6 ?C�4 /1 G Construction Supervisor's License#(if applicable) ��7 /t/ ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) Re-roof(hurricane nailed)(stripping old shingles) All construction debris will betaken to 0v, ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows ❑ Smoke/Carbon Monoxide detectors 4 floor plags marked with red S and inspections required. Separate Electrical&Fire Permits required. *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 ofthe-dome Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: C:\Users\decollik\AppDataV,oca]\Microsoft\Windows\Temporary Internet Files\Content.Outlook\QRE6ZUBN\E)PRESS.doe Revised 053012 l The Comatonwealth of Massachuseft -_ Department of Inaduso al Accidents Office of Investigations 600 Washington Street _ - Boston,MA 02111 f mip miass:gov/dia Workers' Compensation Insnrrance Affidavit: BuiIders/Contractors/ElectricianslP[umbers Applicant Information Please Print *Alv Name gwsineworgaiintionllndividuai): D Cl/'N e( V I)er . Address: e e City/Statrizip: / O/+n,- od,c o Phone# �O �7�'3 " 3 7-/ Are you an employer.employerf Check the appropriate box: Type,of project(r 4. I am a era/contractor and I P Iect �i��= 1.El I am a employer with 6. New construction employees(full and/or part-time):* have hired the sub-contractors I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling ship and have no employees These sub-contractors have S_ Q Demolition w for me in an employees and have was' o�g y capacity. wars' 4. ❑Building addition. [No workers'comp.insurance; cam-mSlgance- reed-I 5. We are a corporation and its 10-❑Electrical repairs or additions 3. 1 am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself [No workers'comp- right of exemption per ld1GL 12. Roof repairs insurance t c. 152,§1(4),and we have no �" requsred.I employees.[No workers' 13-E Other camp.insurance required.] *Any appKc=that checks box#1 nmst also fill out the section below showing then woiker's'compensation policy information. 1 Homeowners who submit this affidavit indicating they are doing all wo&and then hire outside contractors must submit a new afipdavit indicating such. kontmamrs thud check this WE must attached am additional sheet showing the name of the sub-contractors and state whether or not those entities bwe employees. If the sub-contraetots have employees,they Horst provide their workers'comp.policy number. I am an employer that is prmiding workers'compensation insurance for air etrrpinyee& Below is the policy and fob site informatiom Insurance Company dame:. Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/Statelzip: 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 impositim 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 dle DIA for insurance,coverage verification_ I do hereby ce - under thepains and penalties of petgrtrp that the information provided abow is bw and/correct Si tune: l/G '/" ( Date: // .2 / Phone#: � Official use only. Do not troop in this area,to be completed by city or town offlciai 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 M anRNSrasr E 9� MASS.9 ,�� Town of Barnstable ArfD MA't A Regulatory Services Thomas F.Geiler,Director Building Division Thomas Perry,CB0 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 as Owner of the subject property hereby authorize L- O`"', /1 (_� to act on my behalf, , in all matters relative to work authorized by this building permit application for: , s (Address of Jobs Signature of Owner Date G e D V ( �I Print Name if Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. QAWPFILESIFORWbuilding permit forms\EXPRESS.doC x_ �oFIMETom, Town of Barnstable P �°^ Regulatory Services SARNSTABLE Thomas F.Geiler,Director 9 HAM. g 1639. oip�a`� Building Division Tom Perry,Building Commissioner" 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us. Office:. 508-862-4038 Fax: 508-790-6230 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. At 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 µ 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•shalbact as ' supervisor." F.:. Many homeowners who use.this exemption are unaware that they are assuming the responsibilities of.a supervisor(see Appendix Q Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed.person as it would with a licensed.S upervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that.he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Office:of Consumer Affays&B.smessuad • HOME IMPROVEMENT CONTRACTOR Type. Registration:. 3168722 DBA Expiration 3t390�3. pA L`O NEILL C DANIEL ONE I 9,C APTAIN ISIAH -- . COTUIT,_MA 02635 Undersecretary; . MassaCh BOard Of Usetts _De B Pa Consrructio uildi. Re Part Of p Lice nse°CSFi.s°9' , 2 n aad Sta. afety. D A 1p n»h arils . k. L COtuit�x 1gj1 31-4 02635 _ . COmmissi ner zPi ratio 10/23/2015 q0 C� s Town of Barnstable , C42612-1*Permit it Ess PEREExpires 6 nio m t ,40e , MkTgulatory Semees Fee "SS NOV 2 O 2012 Thomas F. Geiler,Director 1e�� Building Division V wN OF BARNST2! erry,CBO, Building.Commissioner 29 Main Street,Hyannis',MA 02601 . www.town.barnstable.ma us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERNUT APPLICATION. - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Proper ty.Addren 0-7 0 I �: l t �4 X11 I it. � , i s . n [Residential Value of Work ; Fe ® 0 Minimum fee of$35.00 for work under$6000:00 Owner's Name&Address I J e. -dtroille //07 O 1r 114 V ` le 61 Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) OWorkman's Compensation Insurance 1 Check one: I am a sole proprietor I am the Homeowner. ave Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) 0 Re-roof(hurricane.nailed)(stripping old shingles) All construction debris will be taken to Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) �CraY Re-side ®a QELC SI�M line l P v. �e.fJ2'� 'd`.'''�- �. #of doors &Replacement Windows/doors/sliders.U-Value Q e 30 (maximum.35)#of windows _ EPSrrioke/Carbon Monoxide detectors floor;plans marked with red S and inspections required.. Separate Electrical&Fire Permits required. *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. copy of the Home Improvement nt actors License&Construction Supervisors License is required. �SIGNATURE: urn virr nD c%L—Na..R.A 4 fn c1RYPRvns d °FtTti Town of Barnstable Regulatory Services BARN5PABLE Thomas F. Geiler,Director, 9�A MASS. `�� rfo 39. Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 026.91 www.town.barnstable.m.a.us Office:. 508-862-4038 Fax: 508-790-6230 �"�.... HOMEOWNER LICENSE EXEMPTION �. Please Print DATE: '4 I '. ._ . iy��'] JOB LOCATION: D 1 .� 't � 44 S numbr street village "HOMEOWNER": I.ONI� v�l .� �V �J ✓+ �� name home phone# work phone# CURRENT MAILING ADDRESS:' city/tcPwn 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: t DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land owwhich 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 under the building permit. (Section 109.1.1) T The undersigned "homeowner"assumes^responsibility for compliance with the State Building Code and other applicable codes, bylaws, rules and regulations. The under gned "homeowne certifies that he/she understands the Town of Barnstable Building Department minimum inspection proc s a e ire n a d tha e/she will comply with said procedures and requirements. __� SI' at re of -meown 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 fbe 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 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with:a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. • To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently-used by several towns. You may care t amend and adopt such a form/certification for use in your community. y: �p THE Tp� �T �0 * BARNSTABLE, +: MASS. Town of Barnstable prFO N1A'�A Regulatory Services Thomas F. Geiler,Director Building Division Thomas Perry,CBO . Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.maus �- Office: 508-862-4038 - Fax: 508-790-6230 Property Owner Must Complete and Sign This' Section If Using A Builder. as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address'of Job) V 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 IWPFILESTORWbuildin g permit forms\EXPRESS,,d2p,— The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations �; 640 Washington Street Bostonh.M 02111 rwww mas&g v1dia. Workers' Compensation Insurances Affidavit: Bnitders/C'ontractors/Etectiic ans/Ph mblers fica at Information f Ptease Print Legibly Narne(Business/Organinflondu lividual)- k' Address: Q its+/Stat&2ip: "�` /lam. Pont: - 0 1 Are you an rmplofer?C et k the appropriate 0MV Tjpe of project(required): I'❑ I am a employer with 4. [ I am general contractor and I p Yg' G..❑Ne�vr construction employees(full and/orpart4ime).* have hired the sub-conh ctors listed on the attached sheet 7. ❑Remodeling 2.El .I.am a sole proprietor or partner- 1 ship.and have no employees Thew sub-contractors have 8_, ❑ Demolition working for me in a capacity. employees and have workers' IIY.capa ty. 2 4. ❑Building addition [to workers' comp.in urance comp.insurance required.] 5. ❑ We are a corporation audits 10.❑Electrical repairs or additions 3.❑ I am a:homeowner doing all.work officers have exercised their 1 I.❑Plumbing repairs or additions myself [No workers,comp. right of exemption per IYIGL 12.❑Roof repairs insurance required.]T c. 152, §1(4),and we have no I employees.(No workers' 13,❑{3ther UJ V'n 1nB$ camp.insurance required.} s 0 14�1(L 'Any applicant that checks box#1 mnst also fill oat tlhe section below showing their workers'compensation policy infbir stion- I Homeowners who submit this affidavit indicating they are doing all welt and then live outside con actors Est submit a new affidavit iodicsting such. lContractors that check this boot must attached an additionsf sheet showkg the nine of the and state whether or not those entities have empley+eu. If the sab--conimatits have employees,they must provide their workers'comp.policy number. r lain all empkyer drat is ptm�i&ng worlrr?.rs'compwlsatioa i7murvtnce for azy�emplo3regas;,Be sty is�lit�P `arrd job site inforena on. -A77 5 - Insurance-Company Name: v 5 -Policy#or Self ins.Lic.#: Expiration Date: Job Site Address: City/'StatelZip: Attach a co of the workers'compensation policy declaration page(showing the h number and ir-att on date PY P P �Y P g ( policy 4 ). i 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 andfor one-year irnprisarrme*as well as civil penalties in the form of a STOP WORK ORDER and a fine I of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for;nstzra ce coverage verififiatian I do h� u the h s s f parjur}'that the informafian pt•m ided nbovv rs.Grua and corm Si G 2 Phone#- � fd © a1 use an[y: Da not in this area,fv be ct mpbte+d by do or tetwi ofciat City or'I'tr m: PermillUcense# Issuing Authority(c*1e+one) 1:Board:of Health 2.Binding Department 3.City/Town Qerlc d.Electrical Inspector S.Plumbing,Inspeector. 6.Other. Gna,t�rt Fersnai� . . Phone#: NOU-13-2012 09:50 From:BAKER & ASSOCIATES 5083626115 To:508 771 5336 P.1/2 Client#:9742 2BAKERAS DATE(MMUITMI ACORD. CERTIFICATE OF LIABILITY INSURANCE 0411612012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHT$UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOY AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COXERAGE AFFORDED BY THE POLICIES 6ELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BEl1NEEN'fHE ISSUING INSURER(S),AUYHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ISS)must he endorsed.If SUBRQ ATION 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 right's to the certificate holder in lieu of such endordement(s)• PRg000491 CONTACT NAME, Dowling df O'Neil Arc N 4ef:508 776-1620 _ (A1c,Nod; `�08778121f! Insurance Agency EI�R - 973(yannough Rd., PO Box 1900 INSURER(a)APFOROING COWRAeE NAIL fl su Hyannis, INRERA;National Grange Mutual Insuranc _ INBURE INSURER a:ABBoclated Employers Insurance _ QBaker&AAAACiates,inc. R16URYR C O Sex 923INSURERD: enterville,MA 02632-0071 wauReR E: INFURCR I! COVERAGES ERTIFICATE NUMBER' REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LIBTE4 BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICAYED. NOTWITHSTANDING ANY RLAQVIREM14NY, YERM OR CONDITION Of ANY CONTRACTOR OTHER DOCUMENT WITH RPSOCC7 TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE APFf}ngED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLV$ION9 AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE $EEN REDVOCO BY PAID CLAIM3. Ill 'TYPE OF INSURANCE ADDINSR BURR -" POLICY NUMBER ill M M LIC �P), LIMITS A . GENERAL LIABILITY MPJ7223M D411912012 0411912011 EAAACHOCCURRENCE $1000000 X COMMERCIAL GENERAL LIABILITY PI3IBSq. RENTED men s544 000 CLAIM&-MAgE O OCCUR Mr G(P(ArIYwIx_perxnn MAP, • PERSONAI„a ADV INJURY $1 000 ODD oENERAI AGGREGATE s2,000,000 GeN'L A60REG-F I,IMIY APPLIES PER. PRODUCTS-COMPIOP AGG f 2,000,000 _ POLICY PROT LOC f CO SIN— LPL 1TJ" AUTOMOBILE LIABILITY IF A pnciwat ANY AUTO BODILY INJURY(Par person) i ALL OW NED SCHEDULCO BODILY INJURY(Per accident) S AUTOS AUTOS NON-OHINGD PROATY tjAMA6 HIRED AUTOS AUTOS Per p nl .,., .. _...._.. a UMERCLLA LIAR OCCUq LACH OCCUHNENCC $ C EXCESS IJAD CLAIMSWAnC ACGRCGAYE ,.E.. S _ DED Y NTION wC STAY DTI+ B WORKEReCOMPI.NSATION WCC500245401201Z 2312012 ON23/201 X re AND EMPLOYERS'LIABILITY ANY PR0PAISTOPJPARTNh W,)(CCUTIVE Y!N E.L.EACH AC.(:tOENT $500 0O4 OFaICFR)UEm FR EXCIA) n N/A c.L.0184W r-MA EMPLOYEE$500 000 (Mande"in NH) If en,deetrilre underE,L.DIBEA$E-POI•IC,Y LIMIT $500,DDD O9=41PTION Of OPERATIONS below " oraCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(Afteoh ACORD 101,Addlflenel Remuka Schedule,it mae spate is roqu)red) Insurance coverage is limited to the terms,conditions,exClusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. EATiFICATIE HOLDER CANCEIWION Town of f3arnst:ibk SHOULD ANY OF YNE A80VE OESCRIBED POLICIES BE CANCELIED BEFORE THE EXPIRATION DATE THEREDIt. NOTICE WILL Be OELIVERED IN 200 Main StreCt. ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis M2L O2601 AUTNORD3D REPItE8tiNTATIVa C 1988.2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) 1 of 1 the ACORO name and logo are regidtarod marks of ACORO I_S1 08049571M94OSe IHE l Town of Barnstable *Permit# 6� 663 Expires 6 months from issue dat . Regulatory Services Fee + BARNSTABLE, v$ MASS. Thomas F. Geiler, Director t6M ♦� � ArED MA'S A Building Division Tom Perry,CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY q Not Valid without Red X-Press Imprint ti1ap/parcel Number Property Address _ e rd A 7 residential Value of Wor /� Minimum fee of$25.00 for work under$6000.00 Owner's Name& Address DG;•�%el O ,,r AV 4,l k tlls,A Contractor'sName #OP7)e oco0e_f Telephone Number 1 lome Improvement Contractor License# (if applicable) Construction Supervisor's License # (if applicable) ❑Workman's Compensation Insurance -PRESS PERMIT Check one: ❑ ),am a sole proprietor FEB 2 7 2009 I am the Homeowner ❑ I have Worker's Compensation Insurance TOWN OF BARNSTABLE Insurance Company Name Workman's Comp. Policy # Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) Er"Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum .44) }Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e. Historic,Conservation,etc. **Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License is required. SIGNATURE: _ Q:'\\III-11.I.STMMS\building permit forms\EXPRESS.doc Revised 100608 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): ��:n r C0 Address: '3 5l /�7 �,�, �ol !r j"?z 5 �� City/State/Zip: y-v, r' ),GO Phone.#: Are you an employer. Check the appropriate box: Type of project(required): 1.❑ I 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 .2.0 I am a sole proprietor or partner-' listed on the attached sheet 7. .❑Remodeling ship and have no employees These sub-contractors have 8."❑Demolition working for me in any capacity. employees and have workers' 9 ❑Building addition [No workers'-comp.-insurance comp.insurance. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.VI am a homeowner doing all work officers have exercised their I LE]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. Insurance Company Name: — Policy#or Self-ins.Lic.#: 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 tip 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 ce nder the pains andpenalties of perjury that the information provided above is true and correct Signature: Date: or 7 Phone M Official use only. Do not write in this area,to be completed by city or town offWal. City or Town: Permit/License# Issuing Authority(circle one): L'Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: 4 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 ..._-ofthe foregoing engaged in a jomt-enferp�nse —meli ng=tfie legs)-represen�ati ?;�f deceased empk�er;or he-:----- =` --- 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(7)states`Neither the commonwealth nor any of its political subdivisions shall . enter into any contract fm the performance of public worn until acceptable evidence of compliance with the inss.iirance 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),addresses)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. hi addition,an applicant that must submit multiple permittlicense 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 to 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 Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 TO. #617-727-4900 ext 406 or 1-877-MASSAFE Fax#617-727-7749 Revised 1 i-22-06 www.mass.gov/dia 1 � Town of Barnstable y�P��THE fp�y� Regulatory Services swtiN9UZLF Thomas F. Geiler,Director ,,rFD A.O� Building Division Tom Perry,Building Commissioner _... ...._..._ .... ...._.__. .._.._.200 Maid.-Street;-Hyannis;MA 026-01 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: �\ ��.._ JOB LOCATION: number strcctp 'llage "HOMEOWNER!':_/✓ name `� home phone# work phone# CURRENT MAILING ADDRESS: 3�/ /n s;z4n. !� cityhown 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. DEFINMON 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 Bamstable,Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and r ements. gnature 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 worst 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 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a fonnvicertifi cation.for use in your community. Q:forms:homccxempt Sra,� Town of Barnstable Regulatory Services Thomas F.Geiler,Director ���EpM1Cla � Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using ABuilder f ,t r as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: -(Address of Job) Signature of Owner Date Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FO RMS:OVdNERPERMISSION