HomeMy WebLinkAbout0500 OCEAN STREET (6) t�� �'�
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map ' I Application #ca D
Health Division Date Issued
Conservation Division Application Fee P(ao a--,)
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation / Hyannis
Project Street Address {
Village
OwnerYda fA:
1� Address
Telephone
Permit Request
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuati r I Pao •& onstructlon 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 \ 1__'
Basement Finished Area(sq.ft.) Basement Unfinished Area (sq ;
Number of Baths: Full: existing new Half: existing '` new. on
Number of Bedrooms: existing —new tl
Total Room Count (not including baths): existing new First Floor Ro m Count`? W
Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other '
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No
Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_
Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size._ Other:
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
Commercial ❑Yes ❑ No If yes, site plan review#
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name ' L 1�')�r�_. Telephone Number S "'
Address c2OL (' �' 6 License#c,J _
Home Improvement Contractor# '1
Worker's Compensation # Raw CSq 1 qC")
ALL CONSTRUCTION DEBRIS R SULT NG FROM THIS PROJECT WILL BE TAKEN TO
n mnk.2d�n
- SIGN ATU DATE ZA, 9/.dory
i
J
FOR OFFICIAL USE ONLY
1 -
APPLICATION#
DATE ISSUED "
MAP/PARCEL NO.
i
ADDRESS VILLAGE
OWNER
F
4
DATE OF INSPECTION:
-Y
FOUNDATION
FRAME
INSULATION
t FIREPLACE
ELECTRICAL: ROUGH FINAL
;{ PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO.
L S
i
s
wig Departmerttoflndus alAccidwfs
--O o Jmesfi anon--.
600 Washington Street '
Boston,'MA 02111 "
Workers' Compensation Insurance Affidavit:Builders/Contractors/FIeciricialis/Plwnbers
ApolicantInforniation' Please Print Le ' l
'Name(Business/Organizati=dhdividnal): V4,ni
•Address: Ed
-
L- 775:�- ItA 0
A r6u an employer? Ch the appropriate bog: Type of prajett(required);
am a employer with 4. ❑I am i general contractor and I
employees(fnll and/or p�rt-tie).
* have hied the sub-contractors 6. ElNew construction
2.❑ I tim a sole proprietor pripartam- listed on the attached sheet 7. ❑Remodeling
These sub--contractors have
ship and have no employees 8, El Demolition
working for me is any'capacity employees and have workers'
[No workers'comp.•in4ance comp.inctmrnoe# 9. Q Building addition
d� 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. Plumb airs or. g; ❑ mg rep 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' 13T, Cher
comp,insurance required]
*Any applicant that checa box#I must!also fll out the=tioa below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are;doing all wodr and then hire outside contractors must submit a new affidavit indicating such,
#Conttactors that check.d is box must attached an additional sheet showing the name of the sob-contractors and state wirethcr or not those entities have
employees• If the sub-contractors have employees,they amst provide their workers'comp.policy m=ber.
I am an employer hhd is providEng workers'compensation insurance for my employees- Below is the policy and job sae
information. ,
Insurance Company Name: 4-4 f7 s Lo
Policy#or Self-ins.Lie.# RAW Expiration Date: 3 3
Job Site Addres
City/State/7_ip: ,® .
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required undm 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-y','ear 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 ce coverage verification.
I ;do hereby certify the a•in I s an of perjury that the information provided above is tr and corr •
Si Date: !'
Phone SOL= ..
tJT='al use-only. Do not write in this area,to be completed by city or fawn off ciaL
City 6r Town: Petrrni:t/Licetase#
Issuing Authority(circle one),:
f.Board of Health 2.BufldhigDepartment 3. City/Town Clerk 4,glectdcal Iaspector. S.•Plombiag lnsp
ector
6. Other
Cant# Person ? ' Phone#:
J.
—- Guard Insurance Group y 4/5
Guard Insurance
DATE(MMJD0/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 07/29/2014
r �
HIS 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
r BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT:BETWEEN THE ISSUING INSURER(S), AUTHORIZED
e _ 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 requite an endorsement: A statement on this certificate does not confer rights to the
r u r a certificate holder in lieu of such endorsement(s).
-.^22.6 •.^+.. CONTACT
a t. PRODUCER NAME: FAX
3 G&O'NEIL INS AGY PHONE
DOWLIN (ABC,No):
E
�✓Y-tom ::-. - -M No,Ext)
973 Iyannough Road E-MAIL
,�-�. •�.,3r+' - ADDRESS:
P.O. BOX 100 INSURER(Sl AFFORDING COVERAGE 11AIC3
Hyannis,MA 02601
R A INSURE : .
t 42390 `
INSURERB: AmGUARD Insurance Company
INSURED -
LLC
Emergency Contractors
INSURER C:
. - INSURER D:
362 Yarmouth Road
Hyannis,MA 02601 INSURER E
INSURER F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POi ICIES 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 SUBJEGT.TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR - AODL SUER POLICY EFF POLICY EXP LIMITS :
lTR TYPE OP.INSURANCE g POLICY NUMBER MMIDDIYYYY MWDDIYYYY GENERAL LIABILITY - EACH OCCURRENCE S _
DAMAGE TO RENTED
t COMMERCIAL GENERAL LIABILITY' PREMISES Ea occurrence) $
1 I CLAIMS-MADE -�X CUR - - MED EXP(Ariy one person} S _
i - - - PERSONAL&AOV INJURY S
GENERAL AGGREGATE `S
j
- PRODUCTS.COMPlOP AGG S .
GENT AGGREGATE LIMIT APPLIES PER: -
PRG- - S .
POLICY JECT LOC
- COMBINED SINGLELIMIT
AUTOMOBILE LIABILITY Ea accident S
- - BODILY INJURY(Per person) S.
.. ANY AUTO-
'i ALL OWNED I. !SCHEDULED I - -BODILY INJURY iPer accident) S
AUTOS AUTOS I - pROPERT'DAMAGE
NON-0WNED _ - _ ;Pcr accidenti _ S
HIRED AUTOS AUTOS I"
UMBRELLA LIAR 0%Cbb:. EACH OCCURRENCE $
EXCESS UAB CLAINIr-MADE I - - AGGREGATE S
! OED RETENTIONS WC STATU- X OTH.
,WORKERS COMPENSATION - - _ TORY LIMITS R' -
I AND EMPLOYERS'LIABILITY Y J N
ANY PROPRIETOR%PARTNEPTXECUTIVE NIA I R2WC 594148 03/03/2014 03/03/2015 E.L EACH ACCIDENT S
.'B I OFRCERT.fEriBER EXCLUOEO�. I� - _ E L DISEASE•EA EMPLOYEE S -
(Mandatory m NH)
I lives describe colder E.L.DISEASE-POLICY UMIT. S - -
DESCRIPTION OF OPERATIONS below ..
DESCRIPTION OF OPERATIONS f LOCATIONS f VEHICLES(Attach ACORD 101,Additional Ramarlls Schcdulo',if rnora spaco is roquirad)
dddl Exclusions:
Scott:Gladish
CERTIFICATE HOLDER CANCELLATION
L '.
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
O 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(201DI06) The ACORD name and logo are registered marks of ACORD
i
-,
The Yachtsman
500 Ocean Street, Hyannis, MA 02601
v'
(achtsman Condominium Trust
P.O. Box 1283
Hyannis, MA 02601-1283
(508)775-1515
DATE
RE: [.snit , Yachtsman Condominium Trust, 500 Ocean Street, Hyannis
To the Town of Barnstable Building Commissioner,
The Board of Trustees for the Yachtsman Condominium Trust voted and approved the
attached proposal to be perfomned as is delineated in the request we.received from the Unit
Owners. This letter serves as notice of that vote to approve the proposal, which has been noted
in the Minutes of the Board Meeting. �y�q
Signe nder th ains and Penalties of Perjury this day of��eL , 20#1q
cre ary,
oard of Trustees
Yachtsman Condominium Trust
500 Ocean Street (c/o Manager's Office)
Hyannis, MA 02601
knc./File
I
Ana rqy� 1.V T111 vy 1/s.al iaV�.wr
o� Regalatox_y-S.er-wes ---- - -
- t 13AINSTABLF, ' — Thomas F.Geller,Director
XAM
9$�1619 Building Division`.
Tom Perry,Building Commissioner
200 Maim Street,Hyannis,MA 02601
w ,w.town.barnstable,ma,us .
Office: 508-862-4038 Fax 508-790-6230
Property Owner Must
Complete and Sign.This Section.
If Usirig A Builder
� �, r;-r?-as Owner of the subject psope_r p
hereby authorize to act on my behalf
in all matters relative to work authorized by this building permit
(Address of Job)
Pool fences.and ala ate the responsibility of the applicant, Pools
rm
are not to be filled or utilized before fence is installed and all final
inspection are pe rmed and.accepted.
✓ Signature pplicant ..
or
Pant Name Print e
ID
Q-F0RMS:0WNERPER2MSI0I P00IS 6a012 _
SHE 1p�� Town of Barnstable
' Regulatory Services
*
* anxxsrwBLe. +
Mass. �, Richard V.Scali,Director
�A 1639. ��
r639.�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
Property Owner Must -------
- Complete and Sign This Section
If Using A Builder - -
property
as Owner of the subject
J
hereby authorize to act on my behalf,
in all matters relative to work authorized by this building permit application for:
f
(Address of J
"Pool fences and alarms are the responsibility of the applicant. Pools
are not to be filled or utilized before fence is installed and all final
inspections are performed and accepted.
Sign e of er Signature Applicant
Of
Print Name Print N ame
201�
D e
Q:FORM&O WNERPERMISSIONPOOLS
Town of Barnstable
Regulatory Services
�oFi►te Tory Richard V.Scali,Director
Building Division
* EARN M ` Tom Perry,Building Commissioner
M6CC
1639 ��� 200 Main Street, Hyannis,MA 02601
CEO A www.town.barnstable.ma.us
Office: 568-862-403 8 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION: - -
number street village
-
name home phone# work phone#
CURRENT MAILING ADDRESS:
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow
homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides.or intends to reside,on which there is,or is intended to be,a one or two-
family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one
home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form
acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit (Section
109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,
bylaws,rules and regulations. _
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection
procedures and requirements and that he/she will comply with said procedures and requirements.
Signature of Homeowner
Approval of Building Official
Note: Three-family dwellings containing-3 5,000 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.IS) 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 Iicensed 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:\WPFILES\FORMS\building permit forms\EXPRESS.doc
Revised 061313
Massachusetts --DePartment of Public Safety
Beard 09'Building Regulations and Standards
�'tx13'+t'k'E1CdHEFt4`?ISjicYS3�i$S' �
License: CS-103622 k
�ti aims ! l
ROBERT S JONE�
206 CEDRIC.RD
CENTERVILIX MA
G�...��I�C�E tq
'.IUn
ar rr3ssia r 03119/2015
i
� � Tt'A
Off ce of Consumer 1�ffairs 4d Business Regulation
10 Part. Plaza. - Suite 51.70
Roston, Massachusetts 02116
Home Improvement Contractor Registration
Registration; 164370
Type Supplement Card
EMERGENCY CONTRACTORS LLC Expiration: 10I1J2015
GM
R. SCOTT JONES s``
73 IYANNOUGH RQ
_ ... _ ............
..
HYANNIS, MA 02601
._.__ .. ....._..
Update Address and return card Alark reason for change.
s h .: €rv- s� Address ' Renewal Employment ; lost Card
� -Office of Consumer Affairs&business Regislation License or registration valid for individui use only
' t� ME IMPROVEMENT CONTRACTOR before the expiration date. if found return to:
Office of Consumer Affairs and Business Regulation
� r ;Registration: 164370 Type 10 Park Plaza-Suite Si lt}
Expiration: 1411/2015 Suppie€nent'�ard Boston.;MA 02116
EMERGENCY CONTRACTORS LLC
R.SCOTT JONES
73 iYANNOUGH RD
HYANNIS,MA 42641 _
Undersecretary Not vattd a tthout signature
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel b4o U Application
Health Division Date Issued
Conservation Division Application Fee
Planning Dept. Permit Fee 1' WA&2
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation/ Hyannis
Project Street Address 500 oca-AN SnzaeT, UN 1 T 54
Village H YA N M i S
Owner C . RA1' F_LA 1)um TR. Address -5'060,Ct°Gtn ST. . HYC..n n 15 Zih;tw�
Telephone_ _(,17-977- 990 w
Permit Request REMODEL K I Trico S1NIZOOYnS , 8W CENWAL A/C
Square feet: 1 st floor: existing M proposed 6 85 2nd floor: existing 7L/O proposed Total neyv
Zoning District Flood Plain Groundwater Overlays
Project Valuation 75j 000i Construction Type v'
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach sup orting d c m ation..
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 XCrawl ❑Walkout ❑ Other
Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft)
Number of Baths: Full: existing Z new O 69"z Half: existing / new
Number of Bedrooms 3 existin _new ROAld
Total Room Count (not including baths): existing 6 new - First Floor Room Count
Heat Type and Fuel: Gas ❑ Oil ❑ Electric ❑ Other
Central Air: XYes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No
Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_
Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other:
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
Commercial ❑Yes ❑ No If yes, site plan review #
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER) - q -
Name MI CHAF-L BoucriER Telephone Number 508 931 " /S8 1
Address BE EAST `sT12ZY License # CS 057 514
NoZTH GAA;fPOtJ +MA b I S3 6 Home Improvement Contractor# APputb FOR
Email MIKE . 80UMM @ MSN . Coln Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE DATE 7 eI
FOR OFFICIAL USE ONLY
APPLICATION# .
DATE ISSUED ;
MAP PARCEL NO.
ADDRESS VILLAGE
OWNER tita
DATE OF INSPECTION:
' FOUNDATION
l
FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL- i
FINAL BUILDING
Y
DATE CLOSED OUT }
ASSOCIATION PLAN NO.
The Commo iveatth ofAMassaehuseft
Deparhaent of Indksft-hd Accidents
- QO!ke o,f Investigatiions
600 Washington Street
Boston,,MA 02111
wFov.mass.gmaldia
Worke."' Compensation Insurance Affidavit:Builders/Contractors/ ectriciansMumbers
Applicant Information Ptease Print Le ibN
Name(I esslOrg io�rrnd;viaaal�_ �e rn tN ` 0EVe-L o rnaut' LLB -
A Tess ry9 O Yn AI M grkgt 1' . SUITE :0 0
citylst,' Zip: LvA ,. WJV MA. o2y 7 Phone#: z6 r 053 5-
Am you an employer?Check the appropriate box Type of project r
4. ❑ I am a ge�ral contractor sad'I P (required):
etlmred}:
1.A I am a employer with Z 6- ❑New
employees(full and/or part-ime)-* have hirer/the sub-confimaors
I❑ I am a sole proprietor or partner- listed on the attached sheet 7. Retnodelmg
ship said hate no employees These sub-oontractors have g. ❑Demolition
woddag for me.in any capacity. employees and have woaicers' 9- ❑Building addition
[No workem Comp.insurance Comp.mcnrance I
mq ed-] 5.❑ We area corporation and its 10_0 Electrical repairs or additions
3.❑ I am a homeowner doing all work offs bwm exercised their I1-0 Plumbing repairs or additions
nryself [No workers'comp. right of exemption per MGL 12-0 Roof repairs
insurance mod-)t c.152,§1(4),and we ha-M-no
employees-[No workers' 13_❑Other
comp.insurance required-]
ou
*Any ap boat flat checks boa#1 mast also fill out the suction below shaving thek sva leers'mmpensatiaa PoULT Sntotmatia.1-
1 a+ners who submit tlis sTodavn m&cat arg they ate doing an wooir and then bae outside cc mtractors mast snbraa a new affidwot krUrw�Seth.
ZCanto<ctors thst rhea this boot mast sitached an additional sheet showh3g-the name of the sub-cam tamon and state whether or not those entimes have
employees. If the suh-coat mdurs Lase employees,they mast provide their w arkers'comp.policy a=ber .
I rrm an errtplayer#)satin prt»ddirtg tt�orkcrs'cotrrperrsation iirsurarcce for>firJ*RmpinyeRs Belotr is thegoTicp and}ob site
infotmatt an_
Insurance Company-Name: L1�ER'l� MUTUAL
Policy ft or self ins.Lie-;: UJC 5-,RS-3 8 Z"6 -'Q I t{ Expiratio:nDate: )O/1 Z/zols
Job Site Address:S00 OCEAN SfTlE, ()N(T SH Cityistatdzip:N)ANNIS, MA
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as requiredunder Section 25A of MGL c. 152 can lead to the imposition of'rriminal penalties of a
fine up to S 1,500.OU and/or one-year imam as well as char penalties in the fbzm 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 veeificatioto._
I do hereby ce fy under-thapruns andpenabYes ofpedw y that the information prosdded abiwe is hue and correct
A Sieyature- "I Date- 3 ZDI
Phone 9: 6/7 906 - 0 3S
01cial ztse only. Do-not write in this area,to be completed by d3'or town afi'ciaL
City or Town:. PermiVUcense#
Emning Authority(circlet one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
6
L I -R-. 11
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuantto this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer;or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because.of such employment be deemed to be an employer."
-a'..
MGL chapter 152, §25C(6)also states that"every state or Iocal licensing.agencyshatl withhold the issuance or
renewal of a license or permit to operate a business or to constrict buildings in the common-wealth,`.or any
applicant who has not produced,acceptable evidence of compliance with the iasurance..coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any'of its political'subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance vYrith the insurance
requirements of this chapter have been presented to the contracting authority."
C
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 cerbficate(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 Departinent of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtailn 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 are 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 asa reference number. In addition;an applicant
that must submit multiple permit/license applications in any"given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations m' (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or.town may be proN ided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be,Tilled 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 burn 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.
`4 " The Commonwealth of Massachusetts
Department of Industrial Accidents,.
Office of javestigations
600 wac�gan Stmtt
Boston,IAA 02111
Tel.4 617-727-4900 W 4-06 or 1--9 MAS 'E
- Fax#C 17-727-7/49
Revised 4-24-07
Www.mass.gnvldia
s
NOTICE NOTICE
TO TO
EMPLOYEES EMPLOYEES
g.
y
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-727-4900 - http://www.mass.gov/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you
notice that I(we) have provided for payment to our injured employees under the above-mentioned
chapter by insuring with:
LM INSURANCE CORPORATION
NAME OF INSURANCE COMPANY
PO Box 9525,Manchester,NH 03108 (800) 562-3936
ADDRESS OF INSURANCE COMPANY
WC5-31 S-382666-014 10-12-2014 10-12-2015
POLICY NUMBER EFFECTIVE DATES
AFFILIATED INSURANCE 935 JEFFERSON BLVD STE 2001
MANAGERS INC WARWICK,RI 028 (401) 352-3000
NAME OF INSURANCE AGENT ADDRESS PHONE#
POLYMATH DEVELOPMENT LLC AND 590 MAIN ST STE 500 WATERTOWN,MA
DUFFY HOLDINGS LLC 02472
EMPLOYER ADDRESS
EMPLOYER'S WORKERS' COMPENSATION OFFICER(IF ANY) DATE
MEDICAL TREATMENT
The above-named insurer is required in cases of personal injuries arising out of and in the course
of employment to furnish adequate and reasonable hospital and medical services in accordance
with the provisions of the Workers' Compensation Act. A copy of the First Report of Injury must
be given to the injured employee. The employee may select his or her own physician. The
reasonable cost of the services provided by the treating physician will be paid by the insurer, if
the treatment is necessary and reasonably connected to the work related injury. In cases requiring
hospital attention, employees are hereby notified that the insurer has arranged for such attention
at the
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER
Insured Copy
f
Town of Barnstable
Regulatory Services
9 '�� Richard V.Scali,Director
i639. �0
'6 3 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
Property Owner Must
Complete and Sign This Section
If Using A Builder -
I, �• , as Owner of the subject property
hereby authorize M!CHaL 13 aUCHEK to act on my behalf,
in all matters relative to work authorized by this building permit application for.
00 0�-EA: STIRe i uN IT SLI
(Address of Job
"Pool fences and alarms are the responsibility of the applicant. Pools
are not to be filled or utilized before fence is installed and all final
inspections are performed and accepted.
Signature of Owner Signature of Applicant
Po-Ale(a,b)%
Print Name Print Name
NLIV. S c20lq
Date
QTORMS:O WNERPERMISSIONPOOLS
Town of Barnstable
Regulatory Services
��oFE rOtyy Richard V.Scali,Director
Building Division
unxszesr s Tom Perry,Building Commissioner
nrass.
200 Main Street, Hyannis,MA 02601
CFO www.town.barnstable.ma.us
Officer 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 ADDRFSS:
cityAown state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow
homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two-
family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one
home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form
acceptable to the Building Official,that he/she shall be responsible`for all such work performed under the building permit. (Section
109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,
bylaws,rules and regulations. _
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection
procedures and requirements and that he/she will comply with said procedures and requirements.
Signature of Homeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code
Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt
from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner
engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor
(see Appendix Q,Rules &Regulations for Licensing Construction Supervisors,Section 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 Iicensed 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:\WPFILES\FORMS\building permit forms\EXPRESS.doc
Revised 061313
{
yq
-70
Cr
cx
All
W long,
0- 0
cr
"``€
ZT
cr
CD
to 0
cy E
r
_ �31
a i
r
r
U _ 0 a
vp z
" 'sy, s
LY}
Cf2 G, Cc U W
CD
GO
!D
The Yachstman Condo and Trust Give Michael Boucher
authorized to perform work on unit 54 and obtain a
permit.
Robert Rice
r Zerty Man ement
i
Mass. Corporations, external master page Page 1 of 2
W
Corporations Division
Business Entity Summary
ID Number: 001055862 Request certificate( New search
Summary for: POLYMATH DEVELOPMENT LLC
The exact name of the Domestic Limited Liability Company (LLC): POLYMATH
DEVELOPMENT LLC
Entity type: Domestic Limited Liability Company (LLC)
Identification Number: 001055862 Old ID Number:
Date of Organization in Massachusetts:
06-23-2011
Last date certain:
The location or address where the records are maintained (A PO box is not a valid
location or address):
Address: 905 CONCORD AVE.
City or town, State, Zip code, BELMONT, MA 02478 USA
Country:
The name and address of the Resident Agent:
Name: J. PATRICK DUFFY
Address: 905 CONCORD AVE.
City or town, State, Zip code, BELMONT, MA 02478 USA
Country:
The name and business address of each Manager:
Title Individual name Address
MANAGER BREANNE DUFFY 905 CONCORD AVE. BELMONT, MA 02478
USA
—'� MANAGER J. PATRICK DUFFY 905 CONCORD AVE. BELMONT, MA 02478
USA
MANAGER DAMES PATRICK DUFFY 905 CONCORD AVE. BELMONT, MA 02478 UNI
In addition to the manager(s), the name and business address of the person(s)
authorized to execute documents to be filed with the Corporations Division:
Title Individual name Address
SOC SIGNATORY JAMES PATRICK DUFFY BELMONT, MA 02478 UNI
http://corp.sec.state.ma.us/CorpWeb/CorpSearch/CorpSummary.aspx?FEIN=00105 5 862&... 11/6/2014
• V
'3Ab
�w I
_ a �
•VNQ ♦ly 1 • � `�j�
�\ fly � •, _ ,� o
A A ^
• • V L\Y L V 0 a b O r O oo� m� I• O 4� o
• • • • • • AtlM 0� 40,V• � C1 DOO v ra 'S fl O
rj
• • • • • •z KO r_ -r ❑ a 'I�yM� _� g 000 Oe o o ✓o o• a.4 O� _ '� 0 3
O N N O
❑ fi
Si
• • • • • • • �• - W - O o
5� o a
• • • • t� • D� -� 3 'F - U a W •• v
_ o a
a. Q❑
psi Qo44 � oQ o.a pc'
a I• • • �• • � 4 4 4 {,� o°� �''Qpp C1 Q q o � go .� p o o d�
0
Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
Construction c tructio n Supervisor
License:CS-057564 i
MICHAEL N.BO
82 East Street4 _
North Grafton MA 01534,{
r
Expiration
Commissioner 02/25/2016
G+
Unit 52 ,
OP
Existing Cabinets Bath t4
° Ar
ea
rea
w BedroomCD
in
• - - C� Q Q
S '
b, Kitchen Unit 54 �
in
N \Concrete
Patio = -- _. --- - - — - — — - -.----- -- - - — -.
O
b
o -
3F
Unit 5 ro - Unit 54 Leve l 1
SCALE APPROVED DRAUJN BY
DATE October 13, 201 REVISED
Existing Plan
DRAWING 'NUMBER
I OF
oG
NgswnN IVNIM'VNCI
��lc� pasodo,��
C3991ASN loz '.El Jagovoo a.L17a
hG NmV-aia C3SAoNc4c4lv
i isAa-1 irs ilu 1 ,
gs ijun
irs iiun
ma
a
4
o
u
a}a�aouo7
N
o n, "s
I o
I I I I I
p
Q
• ao�u.�n� s�.aulgt�7 n
rffl
! J1V' 10H maN uayp}l>f maN o
uo
- p 7 o/b` ma N
1.
Zs- i!un
Unit 52 -
- 4 -3i4' �
0
O O
d
a
,n o Bedroom I
F
1 I 1 1
1
1 1 1 I
_ 1 : {
Living: Room I 1 1 1
Open To
• Below -p ,;
` CM
a
a
� s
1
Unit 59,
f Unit 54 Level. 2
SCALE APPROVED DRAWN 15Y
DATE October 13, 201 REVISED
Existing Plan
DRAWING NUMBER
3 OF &
a
r
Unit S2
42'-3i 11
Reconfigure mechanical chase
to include HVAC Supply trunk
U
Install recessed Bath
Lighting (Typ) u Bedroom
r-Tr
1 1 1
U I 1 d
Living Room
Open To
C`+ Below
N.
� � n
^
Unit 54 Level 2
Unit 5b
SCALE APPROVED DRAWN BY
DATE October 13, 201 REVISED
Proposed Plan
DRAWING .NUMBER
_ s
9 3 ® S
N39wnN :vNlm'vNa
uqlc4 aullslx gs ilun
Q3SIJ«2� fOZ '�l �ago��0 �1t�O ,.
Ag Nff VN(3 03J�OJdat17" 3�17`�S
jE JGA9-1 irs ilun
b
, , x
46
Ji
ZI N
fitOto"yg d, �-
O} UaGl®
nsT�"p x
woaapag .o
i s i l un Spnis
N
„ti8-,ttr
va ilun
a -
9 j ,
Unit 52
E
New HVAC Closet '
Study Bath
/< Unit 54
Bedroom
R.O. 2'-8°
N
0 '
d
New Wall with interior door.
R O. s'-oy�V x 4-0-4j°
q Open to
Below
N a
Deck
R
X
0
Unit 54 Level 3 .
SCALE APPROVED DRAWN BY
DATE October 13, 201 REVISED
Unit 5roProposed Flan
DRAWING NUMBER
6 6F G