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HomeMy WebLinkAbout0500 OCEAN STREET (25) fi Lv,`i q4 to Applicatio num r.. .. ... ..... 3 Fee ..... . ... ... • M� BUILDING DEPT. Building Inspectojrs Initials. ............................. MAR 0 4 2020 Date Issued.*...3/`�I ' .................. .. . . .. ......... ..... TOWN OF BARNSTABLE Map/Parce3 `T 46 4✓ L/ TOWN-OF BARNSTABLE ' EXPEDITED PERMIT APPLICATION: SCANNED ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEAnMW-ATION MAR 0 5 z0 p PROPERTY INFORMATION Address of Project: ��� O('M4 -S:t' 4 rn q14 NUMBER STREET VII.,LAGE Owner's Name: ] o�0 D Phone Number Email Address: Cell Phone Number 1-)0 Y� Project cost$ ( (( Check one Residential_ Commercial OWNER'S AUTHORIZATION As owner of the above property Y I hereby authorize P to make application foofa building ,t.in accordance with 780 CMR Owner Signature: L - Date: TYPE OF WORK ❑ Siding 5 Windows(no header change)#_❑ Insulation/Weatherization ❑ Doors(no header change)# Commercial Doors require an inspector's review ❑ Roof(not applying more than-1 layer of shingles) _ Construction Debris will be going to CONTRACTOR'S INFORMATION Contractor's name Home Improvement Contractors Registration(if applicable)# 1 1 7 6' D (attach copy) ,A , f Constivciion'Supervisor's License# O (attach copy) Email of Contractor g' L rn Monk-) flo'T �i v Phone number �j 8�6' '77 ? � ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTYIS IN A 0n■errn10 r v^I f AAN ICr nD'TAIAI 11ICrA01/'ADDDAI/AI DCCnDC A DCDAAIrrAA/DC 1«11Cn APPLICATION NUMBER............................................................ *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X , 41 '� X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event i � Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with,the location(s)of each tent Fuel source being used LP tank 20 lbs. or>Yes No—' ,if yes,a gas permit is required. Natural Gas Yes No , if yes,a gas permit is required. If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval, *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massacfiusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT'S SIGNATURE Signature Date All permit applications are subject to a building official's approval prior to issuance. AC Ro o® CERTIFICATE OF LIABILITY INSURANCE DATE(MWDD/YYYY) 03/04/2020 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, EXTENT) OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A C011TRACT BETWEEN--THE ISSUING-1NSURER(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 endorseme►it. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Mark Sylvia MARK SYLVIA INSURANCE AGENCY LLC PHONE — FAx _(A/C.No-E-'I. (506 957-212$ 404 MAIN ST ADORES donna@marksylviainsurance.com INSURERS AFFORDING COVERAGE NAIC# CENTERVILLE MA 02632 INSURERA: AIM MUTUAL INS CO 33758 INSURED STEVEN L MELLOR INSURER IL: C MELLOR BUILDING &REMODELING INSURER _INSURERD: P O BOX 627 — INSURER=_ CENTERVILLE MA 02632 INSURERF: COVERAGES CERTIFICATE NUMBER: 511887 _ REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN IS SUED-rO 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. NSR ADDL SUBR F OULICY EFF' POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYl^� MM/DD LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE1-1 OCCUR DA AGE O R NTED PREMISES Ea occurrence $ N/A MED EXP(Any one person) $ � GEN'L AGGREGATE LIMIT APPLIES PER: PERSONAL&ADV INJURY $ JET LOC GENERAL AGGREGATE $ POLICY PRODUCTS-COMP/OP AGG $ OTHER: AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident AL AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ HIREDAUTOS NON-OWNED AUTOS PROPERTY DAMAGE $ Per accident _ $ UMBRELLA LIAR OCCUR PEACH OCCURRENCE $ EXCESS LIAR DED CLAIMS-MADE NIA AGGREGATE $ i RETENTION$ WORKERS COMPENSATION — $ AND EMPLOYERS'LIABILITY PER OTH- Y/N X STATUTE ER ANV R/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1.,000,000 A OFFICER/MEMBERryinNEXCLUDED? N/A WA N/A AWC40070355822019A 06/17/2019 06/17/2020 (Mandatory in NH) if yes,describe under E.L.DISEASE-EA EMPLOYEE $ 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1-,000,000 N/A 1ESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if mores space is required)pa 4 ) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorserrent WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts, this certificate of insurance shows the policy in force on the date that this certificate was issued(unIVS!;the expiration date on the above policy precedes the issue date of this :ertificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at Nww.mass.gov/lwd/workers-compensation/)nvestigations/. Sole proprietor has not elected coverage. :ERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED.BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Fown of Barnstable Building Department ACCORDANCE WITH THE POLICY PROVISIONS. ?00 Main Street _ AUTHORIZED F.EPRESEiNTATIVE iyannis MA 02601 Daniel M,Gr0 v ey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved: .CORD 25(2014/01) The ACORD name and logo are registerec!marks of ACORD r to air, Tt� s bt The 3 o A/(�aya l�s/ /3'S yG,�/�p.�j'ai i�%a .�q���y' ',���y��4 G 5. .. .„ .... y 5.' �cw.drmrvriziir, -: ,ram Wr„r w.,.v,� 'prim-.... .«,�.wu,,,rw ....o. ..... ,• . .. �. y Z r 'r8k".'///E. .°'a/rEy w"ai/' y�� ,/3 '/"i%5ga� J' xM t irp �.�,. ivo k. 81Sl 3�3,.1�. 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H//i///%/y /ice /#/5N (fr ,/,,,f rW�.wvwwuru.�i �m /i riN,:, ri� .- .ro /ii//mi.�rfa rrrr • t 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): S6/1 1' Address: City/State/Zip: M (= hone#: 9 7 7 C IJ Z 1ij_ Are y u an employer?Check the appropriate box: Type of project(required): 1.Are a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner listed on the attached sheet. 7.; ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition workingfor me in an capacity. employees and have workers' Y P h'• t 9. ❑Building addition [No workers'comp.insurance comp.insurance. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions ] officers have exercised their. 11. Plumbin re airs or additions 3.❑ I am a homeowner doing all work ❑ g p myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152,§1(4),and we have no R 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: "-Lb, MjAko Policy#or Self-ins.Lic.#: yV ���� Q raa � Expiration Date: G6:2 (� w City/State/Zip: O.A 4 Job Site Address: h'/State/Zi P Attach a copy o the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce jy under the pains and allies of perjury that the information provided above ' truq and corrects Si afore: Date: a v Phone#: 5? 2 L Official use only. Do not write in this area,to be completed by city or town ofciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of 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." 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 for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability.Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permitilicense 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 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 y Fax#617-727-7749 www.mm.gov/dia Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only T !EP Individual before the expiration date. If found return to: Reaistr-&io?r_ Expiration Office of Consumer Affairs and Business Regulation 63fl-... -= 11/02/2020 1000 Washington Street-Suite 710 STEVEN L ME'� _ F� Boston,MA 02118 STEVEN L.MEL.. 74 FROST LN ° � HYANNIS,MA 02601.M Undersecretary Not valid without signature •. Commonwealth of Massachusetts a�! Division of Professional Licensure Board of Building Regulations and Standards Constrq-tfl bi p rvisor CS-049879 ires 05/22/2020 STEVEN L.MLOR - P.O.BOX 627 - -- CENTERVILLE 6iF 0266 �Lf)!Sti Commissioner C j