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Home My WebLink About0039 OAK NECK ROAD (,39 ()o K ^^ �nrara7 1 d-92 5082401bbb Town of Barnstable *permit ble Expires 6 months from iss�ate Services Fee Regulatory for Thomas F.Geller)Dire ctor Bullg din D1Vi$10n Tom Perry,CBOT Building Commissioner 200 Main Street,Hyannis,MA 02601 Rww,town.barwtable.ma-us . Fax: 508-790-6230 508-8624038 AFFLICATION - RESIDENTIAL ONZ' EI.YRESS PERMU Not Vaiid without Red X Press Imprint ;el Number V r Address r$b000:00 Minimum fee of$25.00 for work u dential Value of Work s Name&Address Telephone Number .ctor's Name t" #(rf applicable) _.. Improvement Contractor LicenseSSPERM applieabi� IT 2�0� 'orlanan's Compensation Insurance FEB ® 2 = t Check one: `' ; �•� =:. I am a sole proprietor « { , the Homeowner TOWN OF SAR�STABLE ,, am I have Workers Compensation Insurance y.. zranee Comp�y Name L`t )rkman's Comp.Policy# iance Certificate ,py of Insurance Compl must be on file. nest checkbox) ��f oyyC( Recf;& �-�' ,=t Req Re-roof(stripping old shingles) All construction debris will be taken to Going over existing layers of roof) Re-roof(not stripping Re-side e (m�cimum.44) Replacement Windows/doors/sliders. U-V artmentregulations,i.e.Historic,Cmsen'ation,etc. iWhere.required: Issuance of this permit does note ompliance with other town dep Pe1h'O er si P p tY caner Letter of Permised, ***Mote: e H e e ent ontractors License is req A copy ;IGNATM, t_:Forms:exPmtrg ` eviseW306 Op SHE 1p� Town of Barnstable Regulatory Services sAwvszAs , : Thomas F.Geiler,Director MASS. g 039. ,,• Building Division ED MpS 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: 212— 7 JOB LOCATION: / G/7` ` Cvt- ` /Y414,A,-1 f number street �^cif I village "HOMEOWNER": /-� f"�'W t; f, / 3 z name home phone# work phone# CURRENT MAILING ADDRESS: Z S/4,4 A S Gv. G�.eywrc-k city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is,or is intended to be, a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. minim Apec pro dur an eq ' e ents and that he/she will comply with said procedures and re re u ements. Signature of Hom owner 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 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:fomrs:homeexempt The Commonvealth 001assachusetts Department'of lndustrial Accidents Office oflrivestigadons 600 Washington Street . Boston,MA 02111. wfv}v.massgov/dia ' Workers} Compensation InsurAmce.Affidavit: Builders/Contractors/Electriciaus/plu�ers' A licant Information Please Print Le ill Name(Business/OrgauiiatioWhdividuat): /1 ,f/ Address: 0 hj£ �� City/State/dip: S /�-Phone.#: U o `� Are you an employer?'Check the appropriatebo . 1:Q I am a employer with 4, am a ��c ;Type of project(required g ontraator and T ) • employees(full and/or part time)•*, have hireelthe slab-contractors 6• ❑New construction . 2.[] I am a'sole.psopzietor or partner- listed on the'attached sheet: 7. [�Remodeling ship•and have no employees These sub-contractors have -�yorlang for me in any capaci to ees 8• ❑Demolition. ty. � y and have workers' . [No workers' comp.insurance comp,insurance.$'• 9, []Building addition . required.] 5: We are❑ ,a corporation and its � 10,0E1ectrical repairs or adcti-tzons • 3. I am a homeowner doing a7i:wozk _ --—officers-have exercised their , myself.[No workers'comb, right 8f exemption per MGL 11:❑Plumbing repairs or additions insurance.required.]t c, 152,§1(4),and we have no 12,[]Roof repairs employees,[Nb workers' .•13.Q Other ' WmP,insurance required.] *Any applicant that checks box#1 must also.fill out the section below showin' then , f g workers co Homecton that check submit this m must att indicating they are doing all woik and then hire outside ontractors must submi�t new affidavit inndicating such, $Conhactars that check this box must attaioll ched an additional sheet showing the name of the pub-contractors and state whether ar Rfrthose entities Nava employees, If the sub-contractors have employees,theymustproVidbthegwork�,comp,poBcynumber. -ram an employer•that is providing workers'compensation insurance for my employees Beloyv is.the policy and job site'' inform anon. / Insurance Company Na'aie Policy#or Self-ins.Lie,#;. 111/ � - xpirationDate: Job Site Address' QMY/State/Zip: Attach a cope of the workers' cginpdnsation pQlfcy declaration page'(showing the policy number and e Failure,to secure coverage as z expiration date); g equized under Section 25A of-MGL c. 152 can lead to the imposition of criminal penalties of a fine lip t$250,00 a day aga$1,500.00 and/or one-year irnpriso ant,as well as civil penalties in the form of a STOP WORK,ORDBR and a fine e of up to$ inst th vio or, ad ' ed that a c of this statement maybe forwarded to Investigations of the b or insur .e c v ra e ' cation, oPy y fie'Office of Ido hereby carts de the p ' s a en tie perjury that the information prgvided above i true nit correct. Signature:- Date; 2/ :2- Phone#: Off;iaf use only. Do nor write in this area,.to be completed by,city or town off ciat City or Town:' �ermit/License# . Issuing Authority(circle one); 1.Board of Health 2,Building Department 1 City/Town Clerk 4,Electrical Inspector 5. Plumbing Inspector b, Other Contact Person: Phone#• 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 bite, express or implied,oral or written." An employer is defined as I'm individual,partnersbip,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a-deceased employe=, or the receiver or trustee-of an individual,partnership,association or other legal entity,employing employees, However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant cf 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 deerped to bean employer." IvIGL 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 bnsiness or to construct buildings in the commonwealth for any applicant who has not produced-9 ccdptable evidence of compliance with the insurance coverage required,". Additionally,MdL ehaptcr-152,§25C(7)states"Nether tfie commonwealth nor any of its political subdivisions shall enter into any contract for,the perfon:bAce of publ awork until acmp:dble ev dence•afcomp ce,,*,& lie inatrance' requirements of this chapter have been presented'to the contracting authority.'! Applicants . • , ' . i Please fill out the workers'.compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s) of insurance. Limited•LiabilityCompanies'(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. Se advised that this affidavit may be submitted to the'Dep'artment 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' comp ensation•policy,please call the Department at the nui ber listed below. Self-insured companies should enter their . self-insurance license number onthe appropriateiine City or Town Officials Plea.s.e be sure that the affidavit is*complete'and printed legibly. The Department has provided a spacq at the bottom of the,affidavit for yoit to fill out in tha event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number: In addition,as applicant that Trust submit multiple penmit/license applications in any given year,need only submit ono affidavit indicating current policy information"(if necessary)and under"Job Site Address"the applicant should write"an-locations in�_(city'or town.)."A cbpy of the aff davit t4t.has been officially stamped or marked by the city or town maybe 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 io any business or commercial venture (Le, a dog license or permit to bum leaves•eto.)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 tri give vs a can. TheDepalmenfs address,telephone•and fax number.. Dtputrae at.of lateral A.Ccudleints ' of 110�of Invest taus TO.0 617-7274000 ext 406 or 1-877-MASSAFE Revised 11-22-06. FMC#617- 7-770 02/01/2007 14:52 5082401860 PJDQW PAGE 03 AR WCIP Liberty ISSUING OFFICE, 354 Workers Compensation and INFORMATION PAGE Employers Liability Policy ACCOUNT NO. SUB ACCT NO. Liberty Mutual Insurance Group/Boston 1-342421 0000 LIBERTY MUTUAL F[RE INSUira,NCE Cn, POLICY NO, TD/CD SALES OFFJCE CODE SALES CODE N/R 1ST WC2-31S•342421-016 XX X WESTON 102 REPRESENTATIVE 3000 2 YEAR ASSIGNED 2003 Item 1.Name of CRESWELL CONSTRUCTION CO INC Insured FEIN 73.1641054 Address 195 PINE ST RISK ID 000134545 CENTERVILLE,MA 02632 Status 03 CORPORATION Other workplaces not shown above: SEE ITEM 4 Ma Day Year Mo,Day Year Item 2.Policy Period:From 04-19-06 to 04-19.07 12:01 AM standard time at the address of the insured as stated herein. Item 3. Coverage A. Workers Compensation Insurancc: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A.The limits of out liability under Part Two are: Bodily Injury by Accident 500,000 each accident Bodily Injury by Disease 500,000 policy limit Bodily Injury by Disease 500,000 each employee C. Other States.I..nsurancc: Part Three of the policy applies to the:states,if any,listed here. SEE END WC 20 03 06A D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE Item 4. Premium - The premium for this policy will be determined by our Manuals of Rules Classifications Rates and Rating Plans. All information rc uired below is subject to verification and char, e b audit. Premumn Basis Rates LINE 110 Eatlmntt:d Per SIO0 Estimated Code Total Annual of RE- Cla$�Cat10I1.4 AttnUal ' Premiums SFE EXTFNSIQN OF INFORMATION PAGE No. Pretninms muneration Minimum Premium $ 500 MA Total Estimated Annual Premium $ Interim adjustment of Premium shall be made: ANNUAL This policy,including all endorsements issued therewith,is hereby countersigned by AatA�rlyed Reprr,�nta fe Dnlr 05.11-og _ Loa Code Tcrm. oiler, it Basis Periodic Paymmt Rating B89is Pot.fI,G. k)omc Slate 05-11,-06 Dividend RENEWAL OF: NR MA WC2.31S-34242.1-015 GPO 4030 R1 Copyright 1987 National Council on Compensation Insurance WCo0onM.A BROKER caRr 02/01/2007 14:52 5082401860 PJDQW PAGE 02 MASSACHUSETTS ASSIGNED RiSK POOL REQUEST FOR CERTIFICATE OF INSURANCE Use this form to request a Certificate of Insurance from an Assigned Risk Pool Carrier. Please provide all of the requested information, including the facsimile number($) of the person or persons to whom the Certificate of Insurance should be issued. If this form is fully and accurately completed,the Certificate of Insurance will be issued and distributed by facsimile to each fax number provided below,within two(2) business days of the carrier's receipt. This Form may be mailed or faxed to the Assigned Risk Pool Carrier. To obtain each carrier's contact information refer to the Certificates of insurance section located in the Producer Community section of the Bureau's website, (www.wcribma.org). 1. Name, address, telephone number and facsimile number of the INSURED: Name: Creswell Construction Company Inc. Mailing Address: 195 Pine Street Centerville, M602L632 Physical Address:. Phone: Fax: 508-778-2926 2. Name, address, telephone number and facsimile number of the CERTIFICATE HOLDER: Name: Town of Barnstable Building ❑"vision Mailing Address: 200 M in Street Hyannis, MA 02601 Physical Address: Phone: ^ Fax: 3. Name, address, contact person, telephone number and facsimile number of the PRODUCER: Name: Kerry Insurance A enc Mailing Address: PO Box 1945 North Eastham MA 02651 Contact Person: Scott Kerry Phone: 508-255-8000 Fax: 508-240-1860 4. Policy Number, Policy Effective Date and Policy apiration Date If a Certificate of Insurance is needed for more than one policy term, provide the Policy Number, Effective Date and Expiration Date for each policy term. If the policy has not yet been issued, you must attach a copy of the Notice of Assignment. Policy Number: 3424210106 Effective Date: 4119106 Expiration Date: 4119/07 S. List any special requests for optional coverages/endorsemenis(see Page 2 for listing of coverages available in the pool and the conditions of availability) or additional information(including changes in exposure not yet f reported to the carrier) that will assist the carrier in the issuance of the Certificate oflnsurance, NOTE: An additional insured(s) shall not be listed on any Certificate of Insurance unless such additional insured(s) is a named insured on the policy, 02/01/2007 14:52 5082401860 PJDQW PAGE 01 N N N :N 0 2 0 1 0 7.. ...... PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION KERRY INSURANCE AGENCY INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR EASTRAM COMMON ROUTE 6 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P 0 aOX 1945 COMPANIES AFFORDING COVERAGE NORTH EASTHALM MA 02651 COMPANY INSURED A WORCESTER INSURANCE COMPANy—.---. GOMPANY CRESWELL CONSTRUCTION CO. INC. B COMPANY 195 PINE STREET C CENTERVILLE MA 02632 COMPANY D .7 THIS 15 TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BEI.OW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY' PCRIOD 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 10OLIQlas DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY RXPIRATION LIMITS LTR DATE(MMIDONY) DATE(MMIPDf") dENrRAI,WAGIL.ITY CBSE7050 05715766 —05/19/Q 7 GENERAL AGGREGATE $2 000, 000 X'COMMERCIAL GENERAL LIABILITY 7 CLAIMS MADE OCCUR; PRODUCTS GOMP/OP AGO -$2 000 , 000 7xl PERSONAL ADV INJURY !3 OWNER'S&CONTRACTOR'S PROT EA CH _ H OCCURRENCE $a, 0 0 0, 0 0 0 -FIRE DAMAGE(Anyone fire) $ AUTOMOBILE LIABILITY MED EXP(Any one pomon) 8 51000 ANY AUTO GOMBINED SINGLE LIMIT ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (per peman) HIRED AUTOS N-OWNED ALIVS BODILY iNjuRy (Per accidard) PROPERTY DAMAGE $ GARAGE UABI LI:T7- - AUTO ONLY-EA ACCIDENT ANY AUTO - OTHF THAN AUTO ONLtE ClHACCIDFNT AGGISEGATEEXCESS LIABILITY EACH OCCURRENCE _ ]UMBRELLA FORM OTHER THAN UMBRELLA FORM AGGPIPGATE WORKERS COMPENSATION AND T&STAIT EMPLOYERS-LIARIUTV y ER THE PROPRIETOR/ -LL EACH.ACCIDENT PARTNEASIEXECUTIVE INCL EL DISEASE-POLICY LIMIT m OFFICERS ARE: EXCL OTHER EL DISEASE-EA EMPLOYEE S DESCRIPTION OF OPERATtONS(LOCATION$NeHICLESISPrCiAt.ITEMS CARPENTRY ".0 ;:X m TOWN OF BARNSTABLE SHOULD ANY OF THE AF)OvE DESCRIBED POLICIES BE CANCELLED 15EFORE T44 BUILDING DIVISION EXPIRATION DATE THIRRI10F, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 200 MAIN STREET 1-0 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, HYANNIS, MA 02601 BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO ORLIOATION OR UA131LITY OF ANY KIND UPON THE 00 nANYi GrNTfj OR RMPRESENTATives, AUTHORIZED REPRESENTATIVE W. Scott Kexr C C