Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0163 SEABROOK ROAD
T- C/ I : 52 CAPE SAVE Weatherization 508-398-0398 December 14,2011 Town of Barnstable �n / Thomas Perry CBO Building Commissioner 200 Main St. Hyannis,MA 02601 RE: Building Permits Dear Mr. Perry, This affidavit is to certify that all work completed for permit application#201104760, Status A, Parcel 307206 at 163 Seabrook Road, Hyannis, Permit type: RADD, and issued on 9/07/2011 has been inspected by a certified Building Performance Institute (BPI) Inspector. R-18 Cellulose insulation was added to the attic.Walls have been dense packed with R-13 cellulose insulation. All work performed meets or exceeds federal and State Requirements. Sincerely, William McCluskey Cape Save 7 Huntington Avenue Suite C, South Yarmouth,MA 02664 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel �`G 6 Application Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic- OKH _ Preservation / Hyannis Project Street Address 6 .�j�,o,G I7 cc �� i Village 14 `/oa)n IS 1� `` 61'An Owner 11S+' �1Q 4 in � ► Address Sou-�'t� S�' lS Telephone '6 6 - T I oLa x i�' Permit Request t e5 cep Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation t1, 06 0, 00 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) o Age of Existing Structure 19 � d Historic House: ❑Yes ❑ No On Old King's lighway: O Yes*] No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other = 00 Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) j Number of Baths: Full: existing new Half: existing j new 'a' Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: XGas ❑ 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 MrL11QkeY /COLP6 3O W12- Telephone Number fa -3 9 y- 0 3 9 R Address �n �-o y License # _ L 1 o�„ b u � l RPa0 J b M O U VI Home Improvement Contractor# I �LI Q 3 Q, Worker's Compensation # 1 3051 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO �'DXKGU+� SIGNATURE DATE '� I L i` FOR OFFICIAL USE ONLY ` APPLICATION# pF L DATE ISSUED Y t MAP/PARCEL NO. • ADDRESS VILLAGE OWNER t r DATE OF INSPECTION: t FOUNDATION FRAME . INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL t PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING r s DATE CLOSED OUT ASSOCIATION PLAN NO. � .r J The Commonwealth of Massachusetts . Department of Industrial 1Acci dents Office of Investigations 600 Washington Street Boston,MA 02111 www massgovldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Annlicant Information Please Print LeLriblY Name(Business/organim ion/Individual): MI C J4 A EA AA9C14%5 iC —W13I& Cft SAU Address: -C, l u o a rv6�tj M, City/State/Zip: YAP_iykng Pla VoWone#: Are you an employer?Check the appropriate box: Type of project(required): 1.[K I am a employer with 1— 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 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' Y9. ❑ 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 I L Plumbing 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 i insurance required.]t c. 152,§1(4),and we have no S tt r' ai'�CNI 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. tContntcton 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'camp.policy number. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: r MZ2C t' (�1 S U 9&1 C-E Policy#or Self-ins.Lie.#: C_ Cibck - A 3- �(5 Expiration Date: 5 l l I� �j _� 1 M Job Site Address: �( J f�1 Q r� "�s ��� - City/State/Zip: qa AA 15. 1' 1 Attach a copy of the workers'compensation policy declaration page(showing the policy n er 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the D1A for insurance coverage verification. I do hereby certify under the pains d enalties erjury that the information provided above is true and correct. k�Signature: f Date: Phone#: 3b$ - 3 9 Official use only. Do not write in this area,to be completed by ci),or town official. City or Town: Permit/License# a 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#: l t T c� CERTIFICATE 4F LIABILITY INSURANCE DATE 1311MIDIN"-M 1/2010 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(ies)must be endorsed. if SUBROGATION IS WANED,subject to the terns and conditions of the policy,certain policy may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements). PRODUCER NAME: Shannon Sperrazza Risk Strategies Company !PHONE (781)986-4400 FAiI (TIi1)9s3-4420 �'..._. 15 Pacella Park Drive A L .ssperrazza@risk-strategi®s.com Suite 240 PRODUCER 00018476 Randolph MA 02368 INSURERM AFFORDING COVERAGE NAIL# _ INSURED INSURMA:Seneca Specialty Insurance Co iNsums-Keatina Group Ins Services Michael McCluskey, DBA: Cape Save BNsuRERc:Chartis Insurance 7 C Huntington Ave INSURER D INSURER E South Yarmouth MA 02644 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1011132675 � 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, 1 EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INS PO EFF POLICY EXP LTR TYPE OF INSURANCE i POLICY NUMBER M MM1D LIMITS GENERAL LlABNTY ! EACH OCCURRENCE ffi 1,000,000 X COMMERCIAL GENERAL LIABILITY ! —, PR M ES E —`$ 50 000 A 'CLAHNS40DE OCCUR BAG1002608 10/16/2010' 0/16/2011�MEDEXP(Myoneperson) $ _ 10,000 _ Bit j PERSONAL&ADV INJURY S 11000,000 GENERAL AGGREGATE I$ 11000,000 GEN'L AGGREGATE LIMIT APPLIES PER i PRODUCTS-COMPIOP AGG ;$ 1,000,000 X ;POLICY'_`JECT PRO- LOC ! $ AUTOMOBILE LIABILITY i COMBINED SINGLE LIMIT $ 1,000,000 ANY O �6208200 11/6/2010 -21/6/2011 (Eaacckism) ! BODILY INJURY(Per person) s ALL OMVNEb AUTOS BODILY ILD YILD Y INJURY(Per accidem) $ SCHEDULED AUTOS PROPERTY DAMAGE X HIRED AUTOS ! !(Per accident) $ X `NON-0VJNED AUTOS i S $ X,UMBRELLA UAB OCCUR j I EACH OCCURRENCE f S 11000,000 EXCESS LtA6 CLAIMS-MADE! AGGREGATE $ 1,000,000 1 ?DEDUCTIBLE � I t1!� �$ B RETENTION $ j 235786UI 70/16/2010 10/16/2011 $ 1.'.m B COIr PENSATION ey ! 1MC STATU 1 !OTH• �' i AND EIAPIOYER3'lBABIUTY �Sichael DlcClusk !X TORY LHI . 1 T ; _ Y!N ' Q E.i_EACH ACCIDENT ;S ANY PROPRIETORIPARTNER/EXECUTIVE I f l8 excluded from coverage j OFFICERIMEMBER EXCLUDED? 7 I N f A 1 1 500,000 (Mandatory in NH) ! i9930951 0/21/2010 10/21/2011;E.L.DISEASE-EA EMPLOYES S 500 000 I i H yes desaibe ceder 1- DESCRIPTION OF OPERATIONS below i i E.L.DISEASE-POLICY LIMIT is 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more spew Is required) Issued as evidence of insurance. Contractors-Executive Supervisors or Executive Superintendents. CERTIFICATE HOLDER CANCELLATION (508)790-2425 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Housing Assistance Corp WITH TH THE POLICY PROVISIONS. Attn- Ruth 460 West Main Street AUTHORIZED REPRESENTATIVE Hyannis, MA 02601-3698 r chael Christian/SMS ACORD 26(2008/09) 01988-2009 ACORD CORPORATION. All rights reserved. INS025(2ww% The ACORD name and logo are registered marks of ACORD — -- 01.4e z == Office of Consumer Affa' s and Business Regulation _ 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 164432 Type: Supplement Card CAPE SAVE Expiration: 10/6/2011 WILLIAM MUCCLUSLEY 8201 S. HOURD CT CHAPEL HILL, NC 27516 Update Address and return card.Mark reason for change. DPS-CAI 0 5OM-an04-GIO1216 J Address � Renewal 0 Employment r Lost Card y,; `�PlC 1�49➢2)IZB%Qf�iIL 6�•6G2k7(GCJZ(luB�if Office of Consumer Affairs&Business Regulation License or registration valid for individul use only r � .HOME IMPROVEMENT CONTRACTOR before the expiration date. IT found return to: Office of Consumer Affairs and Business Regulation a -� Registration:-1'Y64432 Type: 10 Park Plaza-Suite 5170 F :.< v Expiration 10/i312D11. Supplement Card Boston,MA 02116 CAPE SAVE WILLIAM MUCCLUktY:' - 7C HUNTING AVE..' � - — S.YARMOUTH,MA M664 Undersecretary Not valid wi ou signature Massachusetts- Department I►f Public 5afev. Board of Buildim, Re-ulations and Standards Construction Super�risor Specialty License License: CS SL 102776 Restricted to. IC a, WILLIAM MC CLUSKY 37 NAUSET ROAD WEST YARMOUTH, MA 02673 Expiration: 6128/2013 ( ,wnnise+air+' Tr#: 102776 { fi CAPS SAVE Weatherization 508-398-0398 s August 22, 2010 To Whom It May Concern: William J. McCiuskey is an employee of Cape Save. He as authorized to negotiate contracts and building permits for our.company. Michael McCiuskey Cape Save—Owner 929-593-5939 cell 7C Huntington Avenue,South Yarmouth,MA 026" I HC As N'r#o- LANDLORD a.-- TENANT - 6i,. . i +Q �— o � PHONE ��f-7 � }� I a-- PHONE �g Dear Landlord, Your tenant is eligible for services through the Weatherization Program_ Progt yam regulations permit us to spend an average of$5,000.00 in materials and labor per dwellia unit. Program regulations require us to weather-strip and caulk doors and windows- insulate attics, sidewalls and floors. All work is professionally done by established private co"tractors. We will conduct a he inspection and doing the work we l inspection to make rmust have your e that all work spermission.e t tf youcwa annk Your Prior t t making participate in the program, please sign the agreement and return the form to your tenant states that fie• This agree ement 1. You will not rase the rent because of the Weatherization work or for phe year from the time the work is completed. 2. You will not evict your tenant for one year following work completion elate except for good cause related to the-enanf.s failure to pay rent or serious or repeated violation of the terms of tenancy. 3. If you sell the property during the specified period, either the new owner must assume the obligations under the agreement prior to sale, or you must refund to u5 the entire amount of materials and tabor we spent in weatherizing the unit If you request, you will be informed of the estimated measures before they are done and provided with a list of the'actual measures and costs following the completion of the work. We also need proofthat you:own,the,property. A:copy of a CURRENT T listing you as the owner Will satisfy this requirement. Please fill in all blan�BILL.0 DEED enclosed agreement and return with the proof of ownership as soon as m\areas of the out the entire form will result in a delay in processing the application. Po%aibliu. Failure to fill If you have any questions please call Michael Sartori at 508-771-5400, ext. 1Q5 Sincerely, Ruth Bechtold Assistant Director Energy and Home Repair Department TENANT/PROPERTY O%VNEPJAG �fo�.y �� EATH&O� TION AGREEMENT 1. The Parties to this Agreement are thefollowing: (hereafter knownas Tenant), (print your tenants name) (hereafter kno)y.n as Property Owner) (print your name) 6k'' and Housing Assistance Corporation(hereaftef knownkas^Agency). In consideration of the mutual promises hereafter stated;the Parties agree as follows: 2. The date of Agency's signature will be the effective date of this Agreement 3_ Property Owner and Tenant consent and agree that the Agency may do the following with respect to the property located at(street,town) leased or rented to the Tenant: unit# ,and currently a) Enter the premises for the purpose of performing a Weatherization inspection_ b) Enter the premises to perform Weatherization work which the Agency determines in its discretion is necessary and appropriate as a result of the Agency's inspection of the property and in accordance with the appropriate priority list for the type of dwelling. The Agency and the Agency's contractors may also enter the appropriate common areas of the building for the purpose of accomplishing the Weatherization work The Agency and representatives of the Commonwealth of Massachusetts, Department of Housing&Community Development(DHCD)may further enter the property to inspect any and all work hereunder. The Agency will provide reasonable notice of the timing of the Weatherization work and inspections. The Weatherization work will be performed in accordance with the Property Owner's consent as further specked below: INITIAL ONLY ONE OF THE FOLLOWING"""` l 1 consent to performance by the Agency and its contractors of any Weatherization work determined necessary and appropriate by the Agency as a result of its inspection of the property. I understand that the Agency will provide a detailed statement of the actual work performed and the associated value at the completion of work. I will provide a separate consent to performance by the Agency and its contractors of Weatherization work following my receipt of the Agency's inspection report and a statement of the estimated work and associated value. This additional consent will be sent under separate cover as Attachment A. I understand that the Agency will provide a detailed statement of the actual work performed and the associated value at the completion of the work. 4. The Property Owner understands and agrees that any and all work,including related repairs for which the Property may also be eligible,will be performed at the Agency's discretion. The Agency estimated completion of the Weatherization work by the end of 2010. r 5. If the Property Owner is required to make repairs to the property prior to the commencement of Weatherization work by the Agency,the Property Owner will be notified by the Agency and will be required to make the repairs as soon as possible. Except where the Property Owner receives a written extension from the Agency,time is of the essence in the performance of repairs by the Properly Owner_ • &. The Property Owner and Tenant authorize the Agency to receive a statement from the fuel supplier/utility supplier as to the quantity of fuelfutilities used at the above address in each of the past three years and the future three years. The information is to be used only to determine the cost effectiveness of the Weatherization improvements. 7. The Property Owner agrees that the rent for the dwelling unit will not be raised because of any increase in the value thereof due solely to the Weatherization work performed_ 8. In consideration of the Weatherization work hereunder,the Property Owner further agrees that upon the effective date of this Agreement and during a period extending through 2009/10,_approximately one year from the time the work is completed, a) The present rent �mont 11 not be raised for any reason. (The rent amount must be filled in). However,this Paragraph (8a)will be waived by the Agency in writing if,and only if,the premises are leased under a state or federal rent subsidy pro,qram,in which case the actual rent charged by the Owner shall conform to the standards of t.rent subsidy program Please state which Housing,,"idy program your tenant is on and through which Agency:?'���' 1�1 V y_n }1 W VV-, L �a c.��m 1 Y b) The Property Owner will not institute any summary process action for possession except in the case of non-payment of rent or other good cause related to the Tenant(or any successor Tenant). c) In the event the Property Owner decides to sell the premises, Property Owner shall comply with one of the two requirements below: --The Property Owner shall not sell the.premises unless the buyer agrees(with a copy forwarded to the Agency) in writing prior to sale to assume all obligations of the Property owner set out in this Agreement; or The Property Owner shall pay the Agency an amount equal to the cost,as certified by the Agency, of the Weatherization materials installed and labor performed in the premises as of the date of sale. Said amount shall be paid to the Agency immediately upon sale. a 9. .(Applicable only if Tenan#'s heat is included in rental payment and blanks are filled in) At the end of the period set forth in Paragraph 8 above,the rent shall not be raised more than per. - for an additional period of one year, and the provisions of 8b and 8c above shall continue in effect for such period. However,the rent provisions of this Paragraph 9 may be waived by the Agency in writing if, and only if, the premises are leased under a state or federal rent subsidy program, in which case the actual rent charged by the owner shall conform to the standards of the rent subsidy program. I 10. The Parties agree that the terms of this Agreement are incorporated into any other lease or agreement between the Property Owner and the Tenant,and between the Property Owner and any successor Tenant, and if there is any conflict between the provisions of this Agreement and the provisions of such other lease or agreement,the provisions of this Agreement shall govern. However, if such other lease or agreement, including without limitation a lease or agreement under state or federal rent subsidy program, contains stronger protections for the Tenant, such stronger protections shall apply. { ti 11. For breach of this Agreement by the Property Owner, the Property Owner shall reimburse the Agency in an amount equal to-the cost, as certified by the Agency, of the Weatherization materials installed and tabor performed on the premises, as well as attorney's fee and court costs. The Property Owner may also be liable for damages to the Tenant in accordance with applicable law; in such instance,the Property Owner shall reimburse the Tenant for attorney's fees and court costs. Without limiting the foregoing, the Agency may at its option terminate this Agreement, by providing written notice to the Property Owner and Tenant, in the event of breach by the Property Owner or Tenant 12. Performance of the Weatherization work hereunder by the Agency is contingent upon the availability of funds to the Agency from the commonwealth of Massachusetts and the federal.govemment, as well as the eligibility of the Tenant under WAP program requirements. The Agency may terminate this Agreement, by providing written notice to the Property Owner and Tenant, if the Agency determines that the unavailability of funds or ineligibility of the Tenant warrants termination. 13. The Parties acknowledge that this Agreement is under seal. It is intended by the Parties that the Tenant or any successor Tenant is the intended beneficiary of the Agreement and shall have a right of enforcement. Property Own Signature: 1J- YrL- i���v�,� Date. Phone: Address: 148SOUTH sT.REET Tenant Signature ��?a '' Date 7 /J Agency Signature Date i t • . TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map _30'7 Parcel ' Application # Health Division Date Issued J Conservation Division Application Fee J' G Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _Preservation/ Hyannis Project Street Address /63 Cc in Village L _ Owner Address Telephone �� g 771 �- Permit Request Square feet: 1 st floor: existing ry"y proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Val uatioXYs_ s Construction TypeAlwel 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: JWGas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes XNo Fireplaces: Existing 0 New Existing wood/coal stove: ❑Yes XNo Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: :_..J CD Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ c" M' Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use :v APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name " ` ��/�i� Telephone Number Address Exe y��� �/ �J� License # ✓y Home Improvement Contractor# I Worker's Compensation # A&-74 V 300zo::V� ALL CONSTRUCTION DEB LT FROM THIS PROJECT WILL BE TAKEN TO�IIyl 14z tl1,Z DATE SIGNATURE l� F f FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED r MAP/PARCELNO. 'f I ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION 1 FRAME INSULATION a , FIREPLACE $ ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL v GAS: ROUGH FINAL FINAL BUILDING R k DATE CLOSED OUT ASSOCIATION PLAN NO. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street i` r Boston, MA 02111 �-n www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: 5 City/State/Zip: 1k�1evMa) RY-4 Phone #: l -7 —0 -7 Are you an employer? Check the appropriate box: Type of project(required): I'N I am a employer•with / 4. r I I am a general contractor and,1 employees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. [Z Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' 9. Q Building addition [No workers' comp. insurance comp. insurance.# required.] 5. We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LE] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.0 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: xf/ 1�� Policy#or Self-ins. Lic. #: W(i-7o// goc 3U ���� Expiration Date: Job Site Address: �d 3 j�l/✓�7s Ue� - � � City/State/Zip: Gi4.n 7 5 Attach a copy of the workers' compensation policy declaration page(showing the policy n ber 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 t e violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA fo '.sura coverage-verification. I do hereby certify a rl pa nd enaIdes ofperjury that-the information provided above is true and correct. Si nature: Date: // Phone#: �l 7�1� -7 7 Official use only. Do not write in this area, to be completed hy'city or town official City or Town: Permit/License# Issuing Authority (circle one)': 1. Board of Health 2. Building'Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: 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 perfonnance 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 thew orkers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s) 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 pennit/license number which will be used as a 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(ifrlecessary) and under"Job Site Address"the applicant should write"a11 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 burn leavbs 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 Fax # 617-727-7749 Revised 4-24-07 www.rnass.gov/dia f OP ID: MF ACORO' DATE(Mmiowy '�'Y) CERTIFICATE OF LIABILITY INSURANCE 03116/11 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 flRODUCER 781-642-9000 REACT Eastern States Insurance 781-647-3670 A10 Est): (AIC No): Agency, Inc. E-MAIL ADDRESS: 50 Prospect Street PRODUCER ZANDE-1 Waltham,MA 02453 CUSTOMERID#. INSURER(S)AFFORDING COVERAGE NAIC# INSURED Zander Corporation INSURER A:Peerless Insurance Company 24198 8 Elk Run Drive INSURER B:AIM Mutual Insurance Co. 33758 Middleboro,MA 02346 INSURERC: INSURER D: 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 .�TYPE OF INSURANCE ADDL B POLICY EFF POLICY EXP LIMBS LTR INSR WVD POLICY NUMBER MMIDDIYYYY M'MMIDDYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,00 AMAGE TO RENTED A X COMMERCIAL GENERAL LIABILITY CBP8548795 11126N0 11126/11 PRE SES JEa occurrence) $ 100,00 CLAIMS-MADE ®OCCUR MED EXP(Any one person) $ 5,00 PERSONAL&ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $ 2,000,00 1-1 POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT (Ea accident) $ 1,000,00 A ANY AUTO BA8548495 11/26/10 11126/11 BODILY INJURY(Perperson) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE $ X HIREDAUTOS (Peraccident) X NON-OWNEDAUTOS $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DEDUCTIBLE $- RETENTION $ $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER B ANY PROPRIETORIPARTNERIEXECUTIVE YIN WC7011823022009 11126/10 11126/11 E.L.EACH ACCIDENT $ 500,00 OFFICERIMEMBE2 EXCLUDED? ❑ N I A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,00 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Atta--h ACORD 101,Additional Remarks Schedule,if more space is required) Re:163 Seabrook Road,,Hyannis, MA 02601 CERTIFICATE HOLDER CANCELLATION BARNSTH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE The Barnstable Housing THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN g ACCORDANCE WITH THE POLICY PROVISIONS. Authority 142 South Street AUTHORIZED REPRESENTATIVE Hyannis,MA 02601 ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD a• 91w 6mww~eqa TI Office of Consumer Affairs and usiness Regulation 10 Park Plaza - Suite 5170 j Boston, Massachusetts 02116 . Home Improvement Contractor Registration _ O co Registration: 148948 "' N U) Type: Private Corporation = c tO Expiration: 11/9/2011 Tr# 290013 y J ZANDER CORPORATION EDWARD ZANIBONI JR - _, ° a 8 ELK RUN DRIVE W Y � ` MIDDLEBORO, MA 02346 M• -x = a 1i =rL co CV. rn Cl)C O `~ Update Address and return card.Mark reason for change. _ 0 co CD Address Renewal Employment Lost Card __ .0 � m d DPS-CA1 is 50M-04/04-G101216 = m y (n ZCj Z — ✓!ZC -COO�I77/YIZOI'GLUCCLLGfZ �ULd�JJILIUQP. 6 U N O ILV Z 0License or registration valid for individul use onl a o = Office of Consumer Affairs&Business Regulation y 9 W W- w LmLI = before the expiration date. If found return to: �p Q HOME IMPROVEMENT CONTRACTOR `—' Y 0 - Registration: 148948 Office of Consumer Affairs and Business Regulation � i j p Expiration , ..11/9/2Q11 Tr# 290013 YOParkazoa70 W co 2116 Type: Private Corporation 2116 ZANDER CORPORATION' EDWARD ZANIB,ON.I JR 8 ELK RUN DRIVE �4 MIDDLEBORO, MA 02346 Undersecretaryut signature oFTHEr°� Town of Barnstable Regulatory Services + SAWS-TABLE, S, KAsa $ Thomas F. Geiler,Director m °rE16ig. BuiIding Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-62: Property Owner Must Complete and Sign This Section If Using A Builder I, �i , a& Owner of the subject property hereby authorize ���/�F'e ��2per��a�., to act on my behalf, m all matters relative to work authorized by this building permit application for. 16. 71 (Address of Job) —t 7-1 ignature of er Date Print NBNWTABLE HOUSING AMMY 14880UTH SIREEI WAM NM=M If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:F0WS:0 WNERPERMISSI0N a � " Town of Barnstable Of THE rp�y o Regulatory Services BARNSIABLE, Thomas F. Geiler, Director y MAss. 16g9• Building Division /FD '�a Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 ww-w.town.barnstable.ma.us Office: 509-862-4038 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 Persoa(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. t Signature of Homeowner ` Approval of Building Official S Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Constriction 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 persons)for hire to do such work,that such Homeowner shall act as supenrisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supenrisor(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 wtith a)icenscd 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 bt/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may caret amend and adopt such a form/certification for use in your communih,. P, pla fe�o )QLrnv Pr avps� Rf av � U if►vet, t' a63S �� T Town of Barnstable *Permit# Expires 6 months from issue date s Regulatory Services Fee $ Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-8624038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number C9 d Property Address (p -3, / S c)CO-h rn d L O 69A { V,- n.,I i 5 [ Residential Value of Worltt 5 Minimum fee of$�0 for work under$6000.00 Owner's Name&Address r n Ut 00tc L ri Contractor's Name Dri a K 1 4Q_ F6nle- _Tn Pr,-,V-t.M E.r Telephone Number 50-- -7 -.S'1117 8 Home Improvement Contractor License#{if applicable) 10325 7 Construction Supervisor's License# (if applicable) (�,S �P�a`{ ®� �� PERMI t&kman's Compensation Insurance AUG 4 2010 Check one.- El I am a sole proprietor TOWN OF 13ARNSTABLE ❑ I am the Homeowner have Worker's c.Compensation �_j Insurance Insurance Company Name QtznQ c i -A— Z✓1dL 4, .C3 Workman's comp.Policy# P tK, 7 W y 9 4 3 O 1,'),0Ocj Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will betaken to tal(MOLA 1(aAss +t JY. ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side #of doors Replacement Windows/doors/sliders.U-Value (maximum.44)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note:. Property Owner must s'gn Property Owner Letter of Permission. A cop the mprovement Contractors License&Construction Supervisors License is urr SIGNATURE: Q:IWPFMH\FORMSIbuilding permit forins0ORESS.doc Revised 090809 The Commonwealth of Massachusetts Department of Industrial Accidents Off Ice of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aaalicant Information' i' Please Print Leeibly Name(Business/OrganizatioN ;6Individual):S p� V_ t-t we__ Z fbV2.MP-Ai Address: 19c,_, City/State/Zip: 4 i5 MA OcZ(00 Phone#: 4:�d�' -1 7.S - 1-77 3 Are you an employer?Check the appropriate box: Type of project(required): 1.1J �- F am a employer with 4. I am a general contractor and I 6. ❑New construction .1 � employees(full and/or pail-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, 0 Demolition working for me in any capacity. employees and have workers' g Building addition [No workers'comp.insurance comp.insurance.; required.) 5. We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LEl Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.)t c. 152,§1(4),and we have no 13.� Other QuJ employees.[No workers' _j1� KGY7f' 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 subcontractors and state whether or not those entities have employees. If the subcontractors 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 fob site Information. (� Insurance Company Name: 1 Policy#or Self-ins.Lic.#:AEG ZOb q 9 q 3C)I kb 10 Expiration Date: p[ 01 L&31/ e. i �6rvvk_ R t� City/State/Zip: ' h If1'1 ��1t�al Job Site Address: — Attach a copy=of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-yetir 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' anc*<b-Y—Aaizc verification. 1 do hereby certify a er at penalties of perjury that the information provided above Is true and correct. Si nature Date: Phone#: Of eial use only. Don ea,to a complete y city or town offlclaL City or Town: . ,. _Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: tt , Town of Barnstable o „ Regulatory Services ' Thomas F.Geller,Director Fn �'`� Building Division Tom Perry,Building Commissioner 200 Main Strect,Hyannis,MA 02601 www.town.b arnstable.ma.us Office: 508-862-4038 Fax: 508=790-6230 Property Owner Must Complete and Sign This Section If Usin.Ly A Builder 7Y ,as Owner of the subject property hereby authorize r ' LAP— to act on my behalf, in all matters relative to work authorized by'this building permit application for. .(Address of Job) • �X-2�u�ivio 1���� ��—� b Signature of bwner Date BARNSTABLE HOUSING AUTHORITY 146 SOUTH STREET HYANNIS,MA-Ml Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. o-mRMC-nvjnF.RPF.RAdT mow 3 R�® CERTIFICATE OF LIABILITY INSURANCE OP ID DS FDATE(MMIOD/YYYY) SPRIN-1 01 05 10 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Bryden & Sullivan Ins Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 88 Falmouth Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Hyannis MA 02601 Phone: 508-775-6060 Fax:508-790-1414 ' INSURERS AFFORDING COVERAGE NAIC# -------- ..�__._._.. --r ------- ---- - - ---. INSURED (INSURER A: Aaoouated industries of HA I.INSURER B. - Sprinkle Home Improvement Inc. INS_URER_C 199 Barnstable Rd INSURER D H Hyannis MA 02601 ----- _-.- - - -- -- INSURER E.. COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE EEEN 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR NSR TYPE OF INSURANCE POLICY NUMBER POOCY EFiECTfVE jPaCICY EXPIR 41Y6tT�—'--"—-- — --"'--- DATE MM/DDNYYY IDATE MWDD/YYYY — LIMITS GENERAL LIABILITY EACH OCCURRENCE S COMMERCIAL GENERAL LIABILITY PREMISES Ea occurence) ,s 1 CLAIMS MADE OCCUR MEO EXP(Any one person) j$ PERSONAL 8 ADV INJURY I$ _ GENERALAGGREGATE S — r GEN'L AGGREGATE LIMIT P APPLIES PER: i PRODUCTS•COMP/OP AGG $ - — I t ------- t POLICY JECROT I LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) ;$ ALL OWNED AUTOS I BODILY INJURY l (Per person) s SCHEOULEDAUTOS i I— i HIRED -- AUTOS ' BODILY INJURY I NON-OWNED AUTOS � �(Per a $�—ccidenl) � I I I I PROPERTY DAMAGE i s (Per accident) I GARAGE LIABILITY i AUTO ONLY•EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC S' AUTO ONLY: AGG 5 EXCESS I UMBRELLA LIABILITY i ( EACH OCCURRENCE $" j OCCUR CLAIMS MADE ` AGGREGATE s f DEDUCTIBLE ! � — RETENTION $ S WORKERS COMPENSATION AND EMPLOYERS'LIABILITY TORY LIMITS ER ____ A ANY PROPRIETOR/PARTNERIEXECUTIV� AWC7004943012010 01/01/10 01/01/11 E.L.EACH ACCIDENT SSOO000 OFFICER/MEMBER EXCLUDED? LJ - - (Mandatory in NH) ; E.L.DISEASE-EA EMPLOYES 500000 If es,describe under t— SPECIAL PROVISIONS below I E.L.DISEASE-POLICY LIMIT s 500000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION SpRNHI;O DATE THEREOF,THE ISSUING.INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Sprinkle Home Improvement, Inc IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR Fax #508-775-1350 REPRESENTATIVES. Margo Mack AUTHORIZED REPRESENTATIVE 199 Barnstable Rd. Kelley A.Sullivan annis MA 02601 ACORD 25(2009101) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Ol`C ,D � �y� License or registration valid,for individul use only Otrce o onsumer arras srness e u 8 on HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Regssrration: U3757 Type: Office of Consumer Affairs and Business Regulation Expiration: 12 Private Corporatic i 10 Park Plaza-Suite 5170 -- Boston,MA 02116 VSKLE-HOME-# _ _ NC. J Brad Sprinkle v = ; 199 Barnstabte R-d c— HyanniCidA(326171 �� . y � Un>IersecFetafy Not valid without sign ure Mas's:ichus tm etts- Dep:u- r'nt of PutrliC,$ACC Restricted to: 00 Board of Building. Re�„ulations.and Standarrcts 00- Unrestricted Construction Supervisor License 1G-1 2 Family Homes License: CS 6643 • j ; Restricted to: 00 i I BRAD K SPRINKLE ` i Failure to.possess a current edition of the 190 LOTHROPS LANt,` Massachusetts State Building Code W BARNS-ABLE, MA 02668 J is cause for revocation of this license. ! Refer to: WWW-Mass.Gov/DPS Expiration: 10/8/2011 ('ommissiuner Tr#: 5478 I �OfTHE r Town of Barnstable *Permtt# 0 Expires 6 mod s r date Regulatory Services Fee BARNS b MASS. ,�� Thomas F. Geiler,Director �lFD MA't p Building Division Tom Perry,CBO, Building Commissioner 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 cgs Property Address - r - /�T�/��S 14. Residential Value of Work'_-7 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address GlJ/w,� 1a`7;r1-Ze1T1 Contractor's Name Z IJf� !� t7 � Telephone NumberP � y _ Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) M 46 X-PRESS PERMIT ❑Workman's Compensation Insurance Che ne: FEB Z��o I am a sole proprietor ❑ Tam the Homeowner TOWN OF SARNST'AK ❑ I have Worker's Compemation Insurance Insurance Company Name Workman's Comp.Policy# Copy.of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side #of doors. ��Replacement-Windows/,docirs/slid.ers.U-Value , �C1�, (maximum .44)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter.of Permission. A copy of the Home Improvement Contractors License& Construction Supervisors License is require L SIGNATURE: Q:\WPFILESTORNIMbuilding pemut forms\EXPRESS.doc L Die Commonwealth ofAlassachusetts Department oflndustrialAccidents Office oflnvestigations 600 Washington Street BOSto71, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A-p-Hcant Information Please Print Legibly lame (Business/Organization/Individual): t t_t I A PO ED h-aaT-1 Address: City/State/Zip: 6 5\GNU 1 L Or Phone #: Jr O 6 r k-(2 -0 6 UI 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 mployees (full and/or part-time). * have hired the sub-contractors 6. ❑New.construction �2rI am a sole proprietor or partner- listed on the attached sheet.. 7, Q Remodeling ' ship and have no employees These sub-contractors have g. 0 Demolition working for mein any capacity. employees and have workers' Building addition No workers' comp. insurance comp. insurance. required.] 5. We are a corporation and its ME] Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11,0 Plumbing repairs or additions myself. [No workers' comp, right of exemption per MGL 12.0 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. 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 isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site information. Insurance Company Name: Policy# or Self-ins.Lic.#: Expiration Date: . ,lob Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c.'152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office.of Investigations of the DIA for insurance coverage verification. I do hereby certify the pain an penalties ofperjury that the information provided above is trice and correct. r�"`Sj nature'"1 Date: Phone#: 'Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority.(circle one): 1. Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6. Other. Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees Pursuant to this statute, an . " y person in the service of another under any contract of hire, employee y p }ee is defined as ...ever i express or implied, oral or written." corporation or other le a partnership, association, r al entity, or any two or morep $ An employer is deemed as "an.mdividu 1,p p, 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 hose u 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 pen-nit 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 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 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. Anew 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 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: ` 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 Fax # 617-727-7749 Revised 4-24-07 www.mass.gov/dia ♦J . �YHE r� Town of Barnstable Regulatory Services ' BARNSIABLE. ' Thomas F. Geiler,Director a;9;��`� 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 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) , ` ignature 4ofev-1Date J/', Print Name BARNSTABLE HOUSING AUTHO,RI� 146 SOUTH STREET HYANNIS,MA 02MI If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. f Town of ]Barnstable Regulatory Services Thomas F. Geiler,Director BARNsrxBLE, t�059. Building Division °lB10) Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 rvnvw.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION J Please Print DATE: JOB LOCATION: / G number get village "HOMEOWNER": _/z (ale 'y- —rol�ifGh,Q d j home— phone work phone it CURRENT MAILING ADDRESS: ! TCf✓ �-/� v � � A, 02-&D / city/town state zip code current exem lion for"homeowners"was extended to include owner-occupied dwellings of six units or less and The. p for hire who does not possess a license,provided that the owner acts as to allow homeowners to engage an individual P 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 requireme. s. BARNSTABLE HOUSING AUTHORITY 146 SOUTH STREET ignature of Homeow r WANNRS,MA OMI 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 dQ such work,that such Homeowner shall act as supervisor." ware that they are assuming the responsibilities of a supervisor(see Appendix Q, Many homeowners who use this exemption are una 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 caret amend and adopt such a fomi/certification for use in your community. n•\WPF11.F..S\FORMS\homeexempt.DOC ' 47 iVJ t'sSachutittts De partilkilt of Public Sate h - — - Board of Buildin- Re-ulatioits and Sk ndards ;•" ' Restricted to: 1G , Construction Supervisor. License n 00- Unrestricted License: CS 64245 1G- 1 2 Family Homes - NjS'i x'4lf wit Restricted to: 1 G WILLIAM J FOGARTY III 46 VERMEER,CT ; Failure to possess a current edition of the F,•„ OSTERVILLE, MA 02655 Massachusetts State Building Code is cause for revocation of this license. 'I -- -�.• 4 Expiration: 10/28/2010 Refer to: WWW.Mass.Gov/DPS (Lnim isime+r Tr#: 5897 ,.. � � � ;lhe -rpo��� o�✓vLaadacl�u6eCla - � t a,; ,��+a .r 4� . T" IDoard of Building Regulations and Standards HOME IMPFOVEMENT¢CgNTRATOR I ` License or registration valid for indtttdul use on11 t before the expiration date. If found return to: . � Registratiori;.150807 Board of Building Regulations and Standards ' ECp�raban 5/8/2010i?ia 266771 j. One Ashburton Place Rm 1301 Type Individual Boston,Ma.02108 WILLIAM J. FOGA2TY WILLIAM FOGARTY III - 46 VERPliEER COURT�`` a OSTERVILLE,MA 02655 Administrator No valid without signaG ire Q or) Map 302 Parcel , y& R 4'0 Permit# House#. / Date Issued b l Board of Health(3rd floor)(8:15 =9:30/1:00- Feed-. =42 7ConservationOffice(4th floor)(8:30-9:30/1:00-2:00) SEPTIC SXSTEM UST BE Planning Dept. (1st floor/School Admin.Bldg.) INSTALLED IN I&N CE WITH TDefinitiv a Approved by Planning Board 19 � ONMENNDOWH REG *-reet TOWN OF BARNSTABLE, Building Permit Application Projeddress _ _ 10 SEA ti R.ob K Roe o Village -alb yAN nr 1.r Owner CAA.Nr�"te. Novr.N� Arrr�vw�ty Address 1y6 Sou-tii s neaT RXa df%'.; 0i Telephone 5v8 ??/ 7;1a2 Permit Request S7n.;n Aw,P 2EROoT[1 ruA Gr�ul�l[g" aflnox 1'J 29 � First Floor square feet Second Floor % square feet Construction Type Jynn0 f Estimated Project Cost $ $4v, a o Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No 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: 124 Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing oZ New Half: Existing '� New No.of Bedrooms: Existing " New t Total Room Count(not including baths): Existing 9 New First Floor Room Count y Heat Type and Fuel: �d Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes No - Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) - r ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use Builder Information Name a Lm N A A nn.ktv,) Telephone Number Address i3 rgwj-riv,, (�'(�., a..r-3 I License# GS o I I o 3S �E!nplo!jut o� owatr 9oV.S1.01 Home Improvement Contractor# Worker's Compensation# Gv 1 o 3 o a 3 r NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN 13Y r',V i£ ?c✓ti Sr GU.1��'rw✓t,tw •� 4M 32,rl - SIGNATURE �/ DATE V BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) • sir. j FOR OFFICIAL USE ONLY _ PERMIT NO. —3 L 5 � DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE' � OWNER • Nam`' - t � - '~ '�,".'' DATE OFINSPECTION: ' FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL, , ROUGH .. FINAL _ PLUMBING: ROUGH t FINAL', GAS: �, r s ROUGH-* FINAL: t , FINAL;BUILDINO'- • lw.3 i r DATE CLOSED„OUT ASSOCIATION PLAN NO, _ - !� 5/18/95 307.206 163 Seabrook Road Hyannis Owner: Barnstable HOusing Authority F Y t 1 i v Permit 777 J�CC ate Issued 4.` I Etlr�inc��In�CPLt.S3tzi flrx�r) House# Avri A!;;:nnirf�c�_ .floor%Schdol Admin. Bldg i \ARt+erAeLi, t MAM Ucflniti.vc Plan Ap);roved by Planninp Bo rd 19 e3a (Applications procetssedm8:30-9:3U-a.m. & 1 00-2 00 n m) � y, 'TOWN OF BARN STABLE ABLE- Building'Permit Application f'ru 'i Str Lt Address ._._/1,5 ��R (Si�� Fire District - _.. __ Address /Y 1 ov Permit Reyucsr i-,_R-r.o,� f'o..p !� yl sC.�.® s :.` AgL-v-A �Ur1 Flood Pl n �', :•, Water Protection Grandfathered Ol11Ri1 Rid�,_,Ief Ap•�x;afs^�,iithorization Record.d ProposedU. - — crr, E:istin2 Information t, Dwelfin Fype: Single Familyw f mil: $f� Multi-family Age P structure -Basement �?istttrc5,.�use Finished -g—Highway— Unfinished ?•r,jn t_ur of Baths ✓No biBedrootns' Total ltoout Count nit In iudi i baths) f-"--�- -'.�--- First Floor Hra.t Tn�and'ruPl. � apw Fir Central r ea aces c' c c,ta h c ed _ h rD h ru r - - e e c t � c• Pool , Attached Barn None t Sheds -- Other Builder Information Name [��;.J'�•.. Telephone number Adc!ress ---- License_ # ' -------- _. _� 'Home Impmv-(, nContractoris ;3 f �ticRxer s t N1 W CONSTRUCI'ON OR ADDITIONS REQUIRE A SITE PLAN (A.3 BUILT) SHOWING EXISTING, AS WELL AS PROPOSED STRUC7`URES ON THE LJT: ALL CONSTRUCTK�N DEBRIS RESULTING FROM THIS PROJECT WILL'BE TAKEN'TO Protect Cost e �+ t Eee SILi GNATURE DA 4- : B�UII.DING PERIVUT DENIED FOR THE FOLLOWING REASON(S) BPERM T - - ° The Town of Barnstable BAMSTAEMZ KAMleg Department of Health Safety and Environmental Services 1639. '. Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-775-3344 Building Commissioner For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions, along with other requirements. Type of Work: ILL xv c F 8� Est. Cost 1a fi v 0 Address of Work: BAPO K Owner Name: xvfi' .bl c flow►N's R w4e,r., Date of Permit Application: I hereby certifv that: Registration is not required for the following reason(s): Work excluded by law Job under S 1,000 Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor name Registration No. OR Date Owner's name F o►.. :'a A..A A r,n t'.zf. 1.rt. i 6�'Ga: 1.:,'la1d,S!;'-'i•,) C j Y—rrS:f Wit' ' - -�y.kk�.i.L.a• sVk,: ...i.�.S71.4,.T'�1�. 1i4...1�C.iN�?. ' with a principal place of b x dness at: 1 q& 6 a&TH 611r. ill/S "A (Gsi►istser�zm) do hereby certify under the pains and penalties of perjury, that: l am an employer provid'mig workers, compensation coverage for my employees workin: this job. - /l��ss A/AlfR0 0 30;3.5_ lnzscm ancz Comm .4y Poiicsr Number O I am a sole prop rietar and have no one working for me in any capacity. (} I am a sole proprietor, general contractor or homeowner (circle one) and have hired th conrractors listed below who have the following workers' compensation policies: Contractor Insurance Company/Policy Numb Contractor Insurance Company/Policy Numb Contractor Insurance Company/Policy Nurr.G () I am a homeo,,vner performing all the work myself. c• :i�-c:-._._ro� o` .___:e-cat wX to ferczrad tc ttc Of5ce.of lin veai«ors or d e DIA for cc,,Trage verifirz:,cr. ;nd the:f2au:e tc co.ceafe rcc_c:ce erocr x�_cn .A cf MGL 152 ua iuo to the im c.itien ci c;ir;inat pcn;i ies eottsistnt:of a fine er t:,; to S 1,SCf.).G) yE3._ Imrr�C''aEr.;; well <�. Era;��in the fc.-r.,cf STOP WORK ORDER and a fine of S 100.00 a dry a�:rst r-c_ Signed this day of 19 Licensee/Permittee R,,. (3 .d.R Building Department Licensing Board Selectmens Office 41 / Health Department J? 7 7 TC `✓ I^ =OVE =.G= IhF0Rirx/-.TiO11 CALL: 6 i i-727-4900 X403, 40a 0 c5, 409, 7= MASSACHUSE77S HAHR® WORKERS' COMPENSATION P.O. Box 803 GROUP TRUST West Springfield, MA 01090 Phone (413) 733-4430 Serving Your Insurance Needs (800) 932-3112 ,cc FAX (413) 733-7479 CERTIFICATE OF SELF-INSURANCE MEMBER: Barnstable Housing Authority POLICY NUMBER: W1030235 POLICY TERM: 10-01-94 to 10-01-95 Massachusetts NAHRO Workers' Compensation Group Trust Self Retention Coverage.A: Workers'Compensation Insurance- $300,000 Each Accident $300,000 Disease- Policy Limit $300,000 Disease- Each Employee Coverage B: Employers'Liability Insurance- Statutory * $350,000 Self Retention for security guards Reliance National Indemnity Company Specific Excess Insurance Coverage A: Workers'Compensation Insurance- Statutory Coverage B: Employers'Liability Insurance - $1,000,000 Each Accident $1,000,000 Disease-Policy Limit $1,000,000 Disease- Each Employee Policy#NXC 0109319-01 Effective 06/01/94 to 06/01/95 This Certificate of Self-Insurance has been issued to said Member pursuant to the Terms and Conditions of the Participation Agreement, and has been executed on behalf of the Massachusetts NAHRO Workers' Compensation Gr up Trust by the Administrator, Mass West Financial Group, Inc. Thomas K. Randall, Vice President Mass West Financial Group, Inc. • �tME/ Barnstable BAPN�'fABLE. rFoyA,r Housing Authority Brian Harrison Maintenance Supervisor f 146 South Street • Hyannis,MA 02601 • Tel.508-771-7222 F Leased Housing 771-7292 • Fax 778-9312 • TDD 778-5333 1 I Restricted To: AA __ —^"� ;J��l: 1('Ir/I4/JIIr//InPn II� /�• �IJ.1.1(!I'�I/.l/'IIl AB - 35,006 cf enclosed space DEPARTMENT OF PUBLIC SAFETY CONSTRUCTION SUPERVISOR LICENSE ( I SA - Masonry only 16 - i 6 2 Family Homes Number: Expires: Massachusetts State Building Code Restricted To: Be is cause for revocation of this license. II Crj' Lr/ BRIAN D HARRISON ti 12 LELAND ROAD _. ..-. I BREWSTER, MA e2631 -M The Town of Barnstable • a,arrsrAsta: • 1 $ Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissic-! For olTice use only i C Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization. conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than tour dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. ` Type of Work: x"^ '•=���^�f Est.Cosi �p SYD•�a Address of Work: 163 1 I L 1 ISfEA 4&00 P-n - Owner's Name �AIL��!� !'�t Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): _Work excluded by law X_Jo rund-er SI,000. __Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWN PERMIT OR DEALING WITH UNREGISTERED OWNERS PULLING THEIR CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. Date Contractor Name Registration No. OR Date Owners Name The Commonwealth of Massachusetts . .. .......... Department of Industrial Accidents #MCC 91117Y9S&gffZfVffS 600 Washington Street Boston,Mass. 02111 Insurance Workers' Comp ensation n alit % 2: xx name: i4nuil Hoo j, location- 141 /11.1 2"3rWOL r)-p city AYAyva M-4 - phone rf rmin all If. am a homeowner Pe M g work myse - am a,sole r and have no one working i/n,any capacity ❑ 1 am an employer providing workers compensation for my employees working on this job. company name: Jt I . ............ address: Swo-C W city: R_•YA Ar JJ one ri I"�4l`La ntl noHCV 0 U�_ insuninc Co. cowner(circle one)and have hired the contractors listed below who am a sole proprietor, general contractor7 or hom have the following workers' compensation polices: company name- address- ...... phone dtv- . ..... nalkv 0 C InsurnnIE!,N a comranv name- addresi: phone Al. dtv- "011CV4 ....... ffisurance co /, FROM penalties ora fte up to S1.500.00 and/or oF MGL 152 can lead to the imposition of criminal Failure to secure coverage as requiredunder Section 25;�' rifica one veant Imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a tion.tine of S100.00 a day against me- I understand that a copy of his statement may be forwarded to the OMce of Investigations of the DIA for coverage v e I do hereby certify under the p - and penalties of perjury that the information provided above it tru,-and correct. signature Phonc# T61 771 Print name oincizi use only do not write in this area to be completed by city or tam offlcial OBuilding Department city or town:-------------------- pernut/Ucen3e 0 _01.Lcensing Board OSelectmen's OMce C3checi,if immediate response is required L.J C]HeslthDeparonent phone#: ❑Other. contact person:-------------------- tevtsce v,95 PJA) Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law",an employee is defined as every person in the service of another.under any contra 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 o: the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver 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 c building appurtenant thereto shall not because of such employment be deemed to.be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or reneF of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who h. not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions shall enter:into any,contract for the performance of public work until cmn acceptable evidence of compliance with the inace requirements of this chapter Have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of insurance as all affidavits 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. FEE F/I City or Towns 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 perniit/license number which will be used as a reference number. The affidavits may be rearmed io the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you 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 t Department of Industrial Accidents ` Once of Imlestlgadons 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 a. phone#: (617) 727-4900 eat. 406, 409 or 375