Loading...
HomeMy WebLinkAbout0045 BRITTANY DRIVE _ s - �. -ALTERNATIVE .713 1�b WEATHER17ATION $(JI`D!41(y Date—. '� f Tow 91 Town of Barnstable 200 Main St. C Hyannis,MA 02601 Re: Permit# �!!VQ z The Insulation work at 5 n has been completed In accordance with 780CMR, Agency work performed for A Slf 7�St�c t-Q= f . ••Regards Timothy Cabral','. ... President CSL-105454 58 DICI MSON STREET I FALL RIVER,MA 02721 I (508)567-4240 ( ALTERNATIVEWEATHERIl ONOOMAIL.COM ` ' . Town of Barnstalble BLilldlil . : • Post This Card•So.That it i`s Visi6leFromtFie Street.-Approved PlansNlust be=Retained onJob and`this Ca d IVlust`beKept, M"� p Posted Urftil final ) ecion HasBeen Made. • Permit :Ma+ Where a Certificate of'OccupancY is Required,such Building shall Not�be Occupied until a Final Inspection has been made. I, Permit No. B-18-1282 _Applicant Name: ALTERNATIVE WEATHERIZATION, INC. Approvals Date Issued: 05/18/2018 Current Use: Structure Permit Type: Building-Insulation,-Residential Expiration Date: 11/18/2018 Foundation: Location: 45 BRITTANY DRIVE;COTUIT Map/Lot: 026-028 Zoning.District: RF Sheathing: Owner on Record: CRADDOCK;MARIANNETR x, Contra�ctorName ,ALTERNATIVE WEATHERIZATION, Framing: 1 Address:' 45 BRITTANY DR - � 2 KK __Contractoaacensel§75683 COTUIT,-MA 02635 im Ch' ne Description: Weatherization Est'TProject Cost: $5,402.00 y Permit Fee:' $�85.00 Insulation: . Project Review Req: 4. FeePaid: $85.00 Final. way K. ,�, ,� �'•.'i:: Date: 5/18/2018 Plumbing/Gas .. � Es p xr Plumbing: .. Rough Final Plumbing: Building Official Rough Gas: This permit shall be deemed abandoned and invalid unless the work authorized%,y this permit is commenced within six months'afte ssuance. . 3 � � Final Gas: All work authorized by this permit shall conform to the approved application and t�e approved construction documents'for�whichthis permit has been granted. All construction,alterations and changes of use of any building and structures all be incompliance with the local zoning,by I ws and codes. �� �$ �a � ' This permit shall be displayed in a location clearly visible from access street�orroadrand shall beamaintained�open foc public inspection for the entire duration of the Electrical work until the coin letion of the same. y ` p �� ���. � ' � Service: mod✓ tda The Certificate of Occupancy will not be issued until all applicable si natures b the suildin =and,Fire Officals a(eprovidedton this permit. p - y Pp g Y g� P Rough:: Minimum of Five Call Inspections,Required for AILConstruction Work: 1.Foundation or Footing Final: 2.Sheathing Inspection, . 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Low Voltage Rough: ' 4.Wiring&,Plumbing Inspections to be completed prior to Frame Inspection S.Prior to Covering Structural Members(Frame Inspection) Low Voltage Final: 6.Insulation 7.Final Inspection before Occupancy - Health .Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Final Work shall not proceed until the Inspector has approved the various stages of construction. Fire Department "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final: Building plans are to be available on site c ISSUED RECIPIENT All Permit Cards are the property of the APPLICANT- Application Nurnber-:� � BARNSTABM �S o� MASS. &Ijl Permit Fee........................'...............Other Fee................:....... 139- 011VG �7 TotalFee Paid............................... ................................ ...... APR 26 2018 . I 1 .1 . TOWN OF BARNSTftk§ On.. ..................... Permit Approval by.................................On..:........................ BUILDING PERMIT NsrA� �� �a� Map........................................Parcel.... ................................. ...... APPLICATION Section 1-7- Owner's,inforthation'4nd Project'Location' Project Address 6 f�m Village CQIU714— Owners Name HGVJ, QLAALL C(A_dCLcAL_ Owners Legal Address 'City Nfizi w State WA zip 0,2635 Owners.Cell# 3b� E-mail Section 2 — Use of Structure Vse Group 0 Commercial Structure over 35,000 cubic feet ❑ Commercial Structure under 35,000 cubic feet Single/Two Family Dwelling Section 3 —Tipe of Permit New Construction ❑ Move/Relocate ❑ Accessory Structure ❑ Change of use Demo/(entire structure) ❑ Finish Basement F] Family/Amnesty El Fire Alarm Rebuild ❑ Deck Apartment El Sprinkler System Addition ❑ Retaining wall . F] Solar Renovation Pool F� Insulation Other—Specify W El Pool 2_&_A0-f\_ Section 4 - Work Description I +-ic , 810LO4&, V\ edulo T_ A+tkc- - Huo 6twr), Sku�r i.:6," &)C, rooc\V,�s. Nkit_ WA IL4_ a.L& _&pjg� jg?f. Last updated:3/15/2018 Application Number.................................................... Section 5—Detail Cost of Proposed Construction ,��(�a�ll'� Square Footage of Project Age of Structure Dig Safe Number . # Of Bedrooms Existing Total#Of Bedrooms (proposed) 110 MPH Wind Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist ❑ Design Section 6—Project Specifics ❑ Wising ❑ Oil Tank Storage, Smoke Detectors ❑ Plumbing ❑ Gas ❑ Fire Suppression ❑ Heating System ❑ Masonry Chimney ❑ Add/relocate bedroom Water Supply ❑ Public ❑ Private Sewage Disposal ❑ Municipal ❑ On Site Historic District ❑ Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility: I am using a crane ❑ Yes ❑ No Section 7—Flood Zone Flood Zone Designation Within or adjacent to a wetland, coastal bank? Yes ❑ No '❑ Section 8— Zoning Information Zoning District Proposed Use Lot Area Sq. Ft. Total Frontage Percentage of Lot Coverage #of Dwelling Units (on site) Setbacks Front Yard Required Proposed Rear Yard Required Proposed Side Yard Required Proposed Has this property had relief from the Zoning Board in the past? ❑ Yes ❑ No Last updated:3/15/2018 i Application Number........ ....,.,.. Section 9— Construction Supervisor Name 7 y-QuQ. Telephone Number Address 144�11 R City /` V. &­ State _Zip Da 7,2,l License Number `05yN/ License Type u Expiration DateY&X I Contractors Email l l'��'Yla'ftye.w2e� ie�2a�Ei trx,.�g�y�;/. Cell # /',V-6 V, I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required 7$0 CMR an a To f Barnstable..Attach a copy of your license. Signature Date �0�6 Section 10—Home Improvement Contractor Nameg[#- A,�jV� wJL�t.�1 C/'I 2 ar-f► U�'�pTelephone Number '5 6f- gb 7—y,2 V Q Address L-al/-k S't City_t�a / er- State/724_Zip 02 141 Registration Number_ Expiration Date f�J 1 understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780 CMR the Massachusetts State Building.Code I understand the construction inspection procedures,specific inspections and documentation required b CMR a e/�ow o Barnstable. Attach a copy of your H.I.C... Signature !/ / Date Section 11 —Home Owners License Exemption Home Owners 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 Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPL CANT SIGNATURE . Signature Date Print Name✓ / Telephone Numbers E-mail permit to:( / /���Fi`Ve(,�/ ier^iz��r(�i1-� Last updated:3/15/2018 Section 12 —Department Sign-Offs Health Department ❑ Zoning Board(if required) Historic District ❑ Site Plan Review(if required) ❑ i Fire Department ❑ Conservation ❑ For commercial work,please take your plans directly to the fire department for approval. Section 13— Owner's Authorization I, JJ21J gpou_ Ce-a-cV© c , as Owner of the subject property hereby authorize i/vib r to act on my behalf, in all matters relative o w rk authorized by this building permit application for: (Address of job) Signature of Owner date Print Name Last updated:3/15/2018 HOME OWNER WEATHERIZATION WORK PERMIT: PLEASE COMPLETE AND SIGN THIS FORM AS THE APPLICANT HOMEOWNER. hereby consent to and agree that weatherization work may be done by the Weatherization Program of Housing Assistance Corporation on the property located at: 1 The weatherization work done will be based on programmatic priorities and availability of funding and it may include all or some of the following measures: i Weather stripping; air sealing; attic& basement insulation; exterior wall insulation; ventilation is measures In consideration of the weatherization work to be done at my home I agree to the following: 1. I give permission to Housing Assistance Corporation to access the property with such equipment and materials as may be necessary to perform weatherization. 2. The Housing Assistance Corporation reserves the right to inspect the fuel or utility bill for the weatherized unit on an ongoing basis for no more than five (5) years after the weatherization work is completed. I have read the provisions of this agreement and e--rn y consent. Home Owner(signature) r `L i Home Owner email: Date: e1z'1 el Agent:(signature) Date: Agency Approved We erization Company All Cape Energy Alternative Weatherization Cape Cod Insulation Cape Save Cazeault Frontier Energy Solutions Lohr Home Improvement fi 4t Agency Signature: �'L Date: For Natural Gas Customers: I have received the National Grid,Discount Rate Application form from my auditor. Customer Initials The Commonwealth of Massachusetts Department of Industrial Accidents 0 I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly Name (Business/Organization/Individual):ALTERNATIVE WEATHERIZATION, INC. Address:2 LARK STREET City/State/Zip:FALL RIVER, MA 02721 Phone#:508-567-4240 Are you an employer?Check the appropriate box: Type of project(required): 1.�✓ I am a employer with 16 employees(full and/or part-time).' 7. ❑New construction 2 I am a sole proprietor or partnership and have no employees working for in any capacity.[No workers'comp.insurance required.] g me 8• Remodeling 3.O I am a homeowner doing all work myself.[No workers'comp.insurance required.]r 9. El Demolition 4.F1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑ Building addition ensure that all contractors either have workers'compensation insurance or are sole 1 l.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.� p Roof repairs These sub-contractors have employees and have workers'comp.insurance.: 14.[E]OtherINSULATION 6.n We are a corporation and its officers have exercised their right of exemption per MGL c. 152,§1(4),and we have no employees.[No workers'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. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:STAR INSURANCE COMPANY Policy#or Self-ins. �Liicc.#:0849257 00 Expiration Date:4/4/19 Job Site Address: / 13�1 City/State/Zip: Attach a copy of the workers' compensation licy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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 S250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the D1A for insurance coverage verification. 1 do hereby certify under t e pains and pen 'es of jury that the information provided above is true and correct. Signature: Date: Phone#:508-567-42 0 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 5.Plumbing Inspector 6.Other Contact Person: Phone#: �•�•""1 ALTEWEA-01 SNERCINHA CERTIFICATE OF LIABILITY INSURANCE DATEiA"DDNYYY) 03/23/2018 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 poiicy(ies)must have ADDITIONAL INSURED provisions or 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). PRODUCER ACT Christine Costa Mason&Mason Insurance Agency,Inc. PHONE FAx 458 South Ave. AIC No,Ezt):(781)447-5531 A/C.No):(781)447-7230 Whitman,MA 02382 ccosta@masoninsure.com I INSURE S AFFORDING COVERAGE NAIC d INSURER A:Evanston Insurance Co. 35378 .INSURED INSURER8:SafGtV Indemnity 33618 Alternative Weatherization,Inc. INsuRERc:Star Insurance Company 18023 2 Lark Street INSURER D: Fail River,MA 02721 INSURER E I 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 ADOL SUER POLICY NUMBER POLICY EFF POLICY EXP LIMITS I A X COMMERCIAL GENERAL LIABILITY i EACH OCCURRENCE I$ 1,000,000 CLAIMS-MADE L^.'OCCUR X i X 3C42088 06/07/2017 06/0712018 1 PREMISES fFa DAMAGE TO RENTED nce) S 100,0001 MED EXP(Any one on S 5,000 I PERSONAL&ADV INJURY S 1,000,0001 1 GEN'L AGGREGATE LIMIT APPLIES PER I GENERAL AGGREGATE Is 2,000,0001 PRO• �L I II 2, ,00 POLICY JECT � i � I i !PRODUCTS•COMPIOPAGG S 000 OTHER. I i I S B I�AUTOMOBILE LIABILITY (Ea ac;cift I COMBINED SINGLE LIMIT S 1,000,000 I !ANY AUTO X �6237702 1 04/08/2018 j 04/08/2019 BODILY INJURY Per WSW) S OWNED SCHEDULED l AUTOS ONLY X ,AUTOS BRODILY Op INJURY DAMAG(Per accident) S I X I AUTOS ONLY )CIA AUTO ONLD j ( Per emI S 1 I i I S A 1 UMBRELLA LIAR I X JOCCUR EACH OCCURRENCE S 1,000,000 j X EXCESS LIAR CLAIMS-MADEI X X kOBW7126517 j 06/07/2017(06107120181 AGGREGATE S 1,000,000.1 i DEO RETENTIONS I 8 C WORKERS COMPENSATION �WC0849257 )( PER OTH- AND EMPLOYERS LIABILITY YIN 0410412018 04/04/2019 I T500,0001 ANY PROPRIETORIPARTNERJFEXECUTIVE E.L.EACH ACCIDENT S (FFICERJM MAff EXCLUDED? a NIA 500,000 !Mandatory in NN) I E.L.DISEASE-EA EMPLOYEE S Ir yes,describe under 500,000 i DESCRIPTION OF OPERATIONS Delow I E.L.DISEASE-POLICY LIMIT S i 1 1 I i � 1 I DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Action Inc.and NGRID USA,its direct and indirect parents,subsidiaries and affiliates is added as an Additional Insured for General Liability on a Primary& .Noncontributory basis per the terms and conditions of form CG2001(04113),for Ongoing Operations per the terms and conditions of form CG2010(04/13),for 1 'Completed Operations per the terms and conditions of form CG2037(04/13)and Waiver of Subrogation applies per the terms and conditions of form MEGL0241-01(04-11). i Additional Insured for Automobile Liability applies per the terms and conditions of form SCA005(02116). i Excess Liability is a following form. i CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE i NGRID USA THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN i ACCORDANCE WITH THE POLICY PROVISIONS. 40 Sylvan Road Waltham,MA 02461 AUTHORIZED REPRESENTATIVE ACORD 25(2016103) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD #a ,2` � �€ klt�a#cars aids€ ' 1 � Cciristru�:icn Su�t�sor . i 1ftiVitYtitY CA13RAi. _� '� ;�'" , , 'FALL WMER'MA 1Yt7 t ' d$JO$13019 t ' ctlxe ' 04VO Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, MasAchusetts 02116 Home Improveme,l, Eontractor Registration Type: Corporation ALTERNATIVE WEATHERIZATION, INC. '`t >_— = Registration 175683 2 LARK ST t = Expiration: 05/28/2019 FALL RIVER,MA 02721 Update Address and return card. Mark reason for change. SCA': 0 20,M-O5f!3 _M..Address.-i—i ilpsgwai 11 Fn.ninvmpnt rl I ec_t t;arr4_..._-- ,� '%f�« �•:.,nrr_irra.:;ul(j n'•, Iti<�stu�rr�ctl c_ Office of Consumer Affairs&Business Regulation ` HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only " TYPE:Corporation before the expiration date. If found return to: ��+�,�• R�k{I'ation !_xpinftian Office of Consumer Affairs and Business Regulation } _ z175W 05/28/2019 10 Park Plaza-Suite 5170 4r ALTERNATIVE WIVE FfiEAI?ATION,INC. 5n,MA 02118 4 TIMOTHY CABRAL: 2 LARK 5T r FALL RIVER,MA 02721 Undersecretary rA814*10Ut 3T 8t<JYe f Engineering Dept. (3rd floor) Map D Parcel Permit# T� << ~ House# Date Issued Board of Health(3rd floor)(8:15 -9:30/1:00-4:30) FeeO�S. Conservation Office (4th floor)(8:30-9:30/1:00-2:00) Planning Dept.(1st floor/School Admin. Bldg.) ors D Plan Approved by Planning Board 19 ; RNSTABLE TOWN OF BARNSTABLE Building Permit Application )ectStreet Address ldresss Village Owner KU / Address - Telephone Permit Request I First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ CQ 971_1� 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: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half: Existing New No. of Bedrooms: Existing New Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ' ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use Builder Information Name Telephone Number T Address `Z/ �y7,�e�-• C1 �t License# a, d;S-63 S— Home Improvement Contractor# Worker's Compensation# wC Z.3f��'S 3�2 O/y NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FRO T HIS PROJECT WILL BE TAKEN TO lf:=� 1___) /-� SIGNATURE DATE BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) FOR OFFICIAL USE ONLY " ' PERMIT NO. DATE ISSUED - MAP/PARCEL NO. ADDRESS VILLAGE ` OWNER DATE OF INSPECTION: r f FOUNDATION FRAME - INSULATION Li !FIREPLACE i ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS:- ` ROUGH FINAL ' FINAL BUILDING r. t DATE CLOSED OUT ` ASSOCIATION PLAN NO. The Comps nrrcullb of Massachusetts - __.•.i,�: Department oj Industrial.4ccidents ' •� `1_ • ;� _ 1� Ofllceol/ayest/gat/ons . 6110 It mviiingian Street Mass. (12111 Workers' Compensation Insurance AMdayit AR?il�''•.n nformation� _ : _ Please PRiNT•l�ibly __, , , locition• 02 QM �}. nhnne 0 � J7_Of 1 am a homeowner performing all wort:myself. I am a sole proprietor and have no one working in any capacity r__.,a--•.,-.-�r....e-�w--�-'T:-�Ll7r_-gas�.nn.go.R_._.•-•..T�s-.T_..:. ._:. - - -•-- ••••^� -1-'�'''-.H'wwr""''�_----•,�•------�•^ - Wam an empiover providing workers' compen/sa_-tion for my employees working on this job. Somn•Jm•n•Jme• addrece• Z/— Z4nG..SOX-1 'Olt01001 . CON: phone#- insJJrance co I am a sole proprietor. general contractor, or homeowner(circle one) and have hired the contractors listed below who ha%,: the following workers' compensation polices: compnnv n• nte• iddress• city- phone ff• - incur•Jnce co policy to rroo-=-,-•�•::��-'.c-+t-•-- ---v.•—•.•...=���rr�w�.:ri..r:_-c-+�.r.:�c+��=.-�-••...�-g.:�,._ comnan• name: iddre c• cin•- phone#� cur•Jnce co policy a _ Attach additional'shcet if tiecessa li :-v^:_1�' `t�r?�f�ety_..:. ::.� '• . ...�r..•�.+..•otia�_�...w�� .. i-«.+ �ya Failu_re to secure coverage as required under Section Z5A of MGL 152 can lead to the imposition of criminal penalties of a fine up to SIS00.00 andiur unc.•cars'imprisonment as well as civil Penalties in the form of a STOP NVORK ORDER and a fine of S100.00 a day against me. I understand that a cope of this statement may be forwarded to the OMce of investigations of the D1A for coverage verifieation. ' I do herchr cerrifj ender t e s an e1,allies of pedun•that the information prodded above is tme and correct. pdlq St_natun Date Print name •► - Phone# (._' OfMr1.Ci2l use only do not write in this area to be compacted by city or town ofricialit or town; pen mit/licease N 1••1Building Department C3Irccusing Board 0 check if immediate response is required ❑Selectmen's Office (3Iic21th Department contact person: phone#N rOther uemvsed 3.')5 P1A1 Information :and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for the employes. As quoted from the "taw", an emphtme is defined as every person in the service of another under ally contract of hire, express or implied, oral or written. An einpinrer is defined as all individual. partnership, association. corporation or other legal entity, or ally two or mor the foregoing enuaged in a joint enterprise, and including the le-al representatives of a deceased employer. or the receiver or�tnistee of an individual , partnership, association or other legal,entity, employing,employees. However th owner of a dwellina house having not more than three apartments and who resides therein. or the occupant of the dwcllin��: house of another who employs persons to do maintenance, construction or repair work on such dwelling: lie or on the `:rounds or building appurtenant thereto shall not because of such employment be deemed to be an employe MGL chapter 152 section 25 also states that every state'o`r local licensing agency shall withhold the issuance or reneival of a license or permit to operate a business or to construct buildings in the commonwealth for any :applicant iwlao has not produced acceptable evidence of compliance with the insurance coverage required. Additionaliv. neither the commonwealth nor any of its political subdivisions shall enter into'any contract for the performance of public work unt•iI acceptable evidence of compliance,with,the insurance requirements of this chapter 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 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 require-- to obtain a workers" compensation policy, please call the Department at the number listed below. Cin- or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom o the affidavit for you to fill out in the event the Office of Investigations has to contact you regard ina the applicant. Pie. be sure to fill in the permit/license number which will be used as a reference number. 77he affidavits maybe returned 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 question please do not hesitate to give us a call. I 41 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 fax #: (617) 727-7749 �nhnne.-9: ((17) 727-4900 ext. 406. 409 or7S 1 11 of Barnstable _ � o� . : The .Town • 1 d Environmental Services NAM• ' � Department of Health Safely an 1�¢ Building Division Eo fit' S H MA 02601 367 Mafia �+ Y� Ralph Crosses Building Commissione•- O ffice: 508-790-6227 Fax: 508.790-6230 For office use only Permit ao.� Date AFFIDAVIT HOME MIPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION ovation, repair, modernization, uires that the "reconstruction, alterations, renovation, re-exu�g MGL c. 142A !eq removal, demolition, or construction of an addition w,fig units or to conversion, improvement, at least one but not more than owner occupied building containing be done by registered contractors, with structures which are adjacent to such residence or building certain exceptions,along with other requirements. �C Est.Cost Type of Work: YC Address of Worms VC, C Owner's Name S 6 Application: � y Date of Permit I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under S1,00L Building not owner-occupied Owner pulling OwB permit WffK UNREGISTERED Notice is hereby that:TBVR OWN pERMTT OR DEG WORK DO NOT HAVE OWNERS LE ROME 'iJRARA UNDER MGL c.142A VEbWff CONTRACTORS FOR ��� ACCESS TO THE��TION PROGRAM OR 1 SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the ownerr Registration No. Contractor Name Da OR. Owner's Name • � .. „ .. ', ..'•.r • •j a ... ., .. 1,K,.o r.,,,..y-.ems' � vs i{{s r r �.. 7 ati� ' r..i� •"` a f.,.. - �1,x�.�„�{"� r ,�.� �,tif��, •�s���a� rm ,Y} , E r��e V.11111al.1,,J�t.`4 r Y.�L7'C� L*sTC" NEG 4«IER+�9 , im , ��.yy{('s i a � `� � rr', a`�G P aAsn On ass-ras¢saCU c 1i , zsdf } �� i 4ytsk}� �.av� n �Pa spti1 r:. 1w5 c a dr e p r `1•a k� -, -,h r ,t'1"LY e`• T C0� 3RACT,OR ,t• � , �Xpiration4 EMEiv O /Ob 49 ENENT CONTRACTOR 11.2536".� yltrSY s S-1 `` { � pLC•ra � °�wyr '12536 nq'@^.� '..�„``•'�-•s*,��,'�,,';��%, ,�ki �rt,'�' ,� t, t � ,, r•ra� + �,: aReg ,( t♦ -�,•- `2 �r'��sk. .s ,.�, E;,rh.�� �`-�:n,�+ ,��,�5+'.iS y���� t`.k�;�eRp A `^ad�.� p�F1,w. m)r, .y � LS IY aIl OnY�� .;r• f'L1���� �' r �yteti �OBA; 1 G s O4l0;b/97 � ems. Llot= si'~ � re 4.,,•# � �x a* .rt�tt i`°•p tip�' �' P $a � } 1^.�"'rtiF f 'Q 1 a'�r }-a �x<s.�, "a..a...� Ek.. * 4.," „,� cy�• 1 F 7y r,y,,�;��� ERASER -JR11 S t� n. HMS' fir, �, w r to r bEAN �n RISER � "�'�` � r ; �� rS-xt:p5a. X cxc M-dl,ra2 -t`Fi.N r9 r fkr•; Oft a"l. i C.R� is �, ro2ry-Y �.< a „v �� G w s � �' L q� R 60� R „ x �r�� .. f r Ih a >�I-TAR. CI t Y T1A`, 0263� a ,r �31 4 aS �r q�((•+', y y wc ; a NI 4r f • y ����� 5- ., v� � �"e--� J'�-��-'7:���t�•t•��.� ��l`ka: y� l�r :.: �� c4 ���,�.d�ei+�"" i Assessor's ma and lot number %P1 SYSTEM MUST BE//73 p "'i�'�"�"" ""�"""'•' INSTALLED IN COMPLIANCE WITH ARTICLE II STATE Sewage Permit number SANITARY CODE AND DOWN ................�................................ REGULATIONS, �OFTMET��` TOWN OF BAR.NSTABLE r EARNSTAIILL i °moo pYae�� BUILDING INSPECTOR J E' APPLICATION FOR PERMIT TO ..... ... ..... .............................. .......................................................................... i �� ^^( mot—( TYPE OF CONSTRUCTION-,:....�m -�........:.....L.........::......J............................................................................. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ... ..1 � .'p i . Jlf' 1`LV ............. ... .. �........... ................................... ProposedUse ..... ....e:..........�......�.........'...1..1�:!�.�'i.X..l...l��...........................................................\....:.................. Zoning District ,` ...............................................Fire District ............................... . ......................... .............................:...... .. ...... Name of Owner ... r �..�. .�.. ..1 u..... ......Address��--�C� fll... .�:'J��C`'. "(!...�o ................. ,..... v Name of Builder ....(9.. .0.1! .: .U..,J F.......Address ;��.:.��.�C.� ���.���`��ti...���:j��l�U�✓I Nameof Architect ........:�� d:::......G.................................Address ..........................................................,......................... Number of Rooms .... ..�`�.....�? .b. . .............Foundations ../ .�'. : �� ..... ..............:....................... Exterior .....L, .............. ......`�' .[.�( ..1..P... ..............Roofing .. 7�p. ?.. .j. :................................................... / / 0... Floors kvl.�-.�'.h ..... r��... .....Interior L. .. :1. ..G �1 ................................................ Heating . .� ........ .................. `.....................Plumbing J.. � p Fireplace .......6-1.1.e........................................................Approximate Cost ...... .If....6... :................................ . /77 Definitive Plan Approved by Planning Board -----------_______------_----19_______. Area ................ � .G .. ............ Diagram of Lot and Building with Dimensions Fee /�Q SUBJECT TO APPROVAL OF BOARD OF HEALTH a7 v ice✓ v cl 80 77 I hereby agree to conform to all the Rules and Regulations o e o of B nstable regarding e a-ove construction. ./.... .:..... ............ ....... .. r DaYoung, George 16457 - one story No .................. Permit for....................... .. ......... single family dwelling . ............... Location Brittany Driv.e ......................... ............ .................................. George DaYoung Owner .................................................................. f ram Type of Construction .......................................... ................................................................................ #2 Plot ...... Lot .....................0 ........... Permit Granted ........J113-Y..31................19 73 Date of Inspection .................... ...............19 Date Completed .........19 PERMIT REFUSED ................................................................ 19 ................................................... ........................... . ................................................................................ ............................................................................... ............................................................................... Approved ............................................... 19 1�7 ............................................................................... ...............................................................................