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Home My WebLink About0242 CLAMSHELL COVE ROAD a�a _ �? ,� �, i __,_- �_�._�_ _ __ .. . _._ � �_ � � _ i TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Ma P pp` / Parcel � Application # "ZOL f CPO" Health Division Date Issued 2 < Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation / Hyannis Project Street Address Z Z G LAAA 5L+C u, LO t/z_:�- Village GbT-U i T Owner l�i�C i:;,rLYG,n c y_t Address fir—Telephone' 09 6 `7 P�v'-r1a Permit Request 13U►L7 IZc� 5� i� , a 613A(.A f-!D 77_� f=kg,6E NO ?awl - ab -rpSuZA-TP'y Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 5 0 vU-U Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other 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: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: Elexisting ❑ new size—Pool: ❑ existing ❑ new size _ Barn:`0 existing--.0 new size_ rAttached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other": o • � x Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# a Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Dou6 AAUl LF/`� Telephone Number 9-_73 - Zy 9 Address es^,3 (Z_pN License # 5S Q n4&g:2 5 MI1, 444 O'L& y Home Improvement Contractor# 'J 3c Worker's Compensation # �bw G Z"Z R/ ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TOWAI. P A)5 Ef--4_ —1 o N SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL N0. ~ Y ADDRESS , VILLAGE , 4 E OWNER: . Y DATE OF INSPECTION: `r FOUNDATION i FRAME J INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL` PLUMBING: ROUGH FINAL• GAS: ROUGH FINAL FINAL BUILDING - DATE..CLOSED OUT ASSOCIATION PLAN NO. �l oa r Town of Barnstable . 'Regulatory Seryices s ?I"gam Thomas F. GeUer,Director he ass Pr D0.19, ��s $wilding Division Thomas ferry, CB0,Building Coiumissioner 20o Main street, Hyannis,MA 0260 f www.town.barnsta ble.w a.us - 'Office( 509-862-4038 Fax: 508-790-6230 PLAN RE VIE W Map/Parcel: DOS Ud_,5 Project Address P7 81��11dae Builder: A' t'llen The following iterns were noted on reviewing: / -cc C. A, /!� 4 S��Cam►�k'c ' ��'I'��it/ '�7�8•uS E 'f d ��1 I Reviewed by: Date: `� t The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.go v/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeLyibly Name (Business/Organization/Individual): L�A( Address: P b . 'F5njC 0-77 Y City/State/Zip: Ai M/ S MQ Phone #: SOT—�37`'3Zy Cj 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 employees(full and/or part-time).* have hired the sub-contractors 6. ew construction 2.❑ I am a sole proprietor or partner- •listed on the attached shedt. 7. ❑ Remodeling ship and have no employees These sub-contractors have g. ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance.t 9• ❑ Building addition required.] 5. ❑ We are a corporation and its 10.0 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.❑ 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 art doing all work and then hire outside contractors must submit a new affidavit indicating such. kContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those efitities 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: 67 V <p 5UIQAc^!CE— A Policy#or Self-ins. Lic. #: Votit 22 6Z`�/ Expiration Date: -1, Z Job Site Address: t17- tmorm-5961/L (eane� City/State/Zip: r-dN1T /Y64 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-yezificatioil. I do hereby certify under the pains and penalties of perjury that the information provided abo a is true and correct Signature: Date: �- 7-,l Phone#: • 50� 37-3 LH-1 Official use only. Do not write in this area, to be completer)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 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 bec'aiise 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,lic&Riior.fteriit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractors)name(s),address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies(LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required.. Be advised that this affidavit may be.submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the'permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly., The Department has.provided a space at the bottom of the affidavit for you to fill out in the event the Officebf,-InVestigations has'to contact you regarding the applicant. Please.be sure to•fi11 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-subrrlit-one affidavit indicating current policy information.,(ifriecessary) and under"Job Site Address"the applicant-should write"all 19cations 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 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 -, Y. of THE r • sna,+srwat.� v� '"" S.� Town of Barnstable i63 �� Regulatory Services Thomas P. Geiler,Director Building Division Thomas Perry, CBO 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 DOL)6 /4 U1-l.Gti to act on my behalf, in all matters relative to work authorized by this building permit application for: Z "-V e (Address of Job) Signature o wner l5ate Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Intemet Files\Contcnt.OutlooklDDV87Ap21EXPRESS.doc Revised 072110 V Town of Barnstable Regulatory Services ti Thomas F. Geiler,Director �xxsrnat.e, M 0 A—S.t6' Building Division . �0 Tom Perry,Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street vi l lage "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 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 5e responsible for all such work performed under the building,permit, (Section)09.1.1,) 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 Chat hedshe w:ill-.cb4ly'wit4r'.•said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing.of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,oui Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:forms:homcexempt Office fC` . -� ReglstraMo ROVEMAl q airs B� M e' FXpiation:ni .1.383 8T cOA�/T+/�rCss eb'u/atlo Alc _� T n N ev/�Dl t_ 3/2�/2o OR Op G .- `' .- -; )g Type_ sense or 59 Np SAS MUL E_: �jNG A bef°re th registr BBY 1 _..� pfr, a e-V ation wFS Y CN is tip_ `-vim I P ce o f on or to T ARM l l a;, � =' l o ark CO ulne n te, for d- pVTN,'jyA f'1 Boston plaza-S r 4A - 'If found dul use 3 ,Mq 02 ite S1�O s and Bpstne turnY. t0.°nly Uncle ss R16 egulation "Secretary 12 Not v d fit outsignatur e �t�� ClAt o�Pa $ta��a�d'. D�\� r t�oas` Se a ` %040\�x e "-A GS ato. .� Restvicte G�,S \V\-(-' DpU 1GKogy N P p2655 112312012 a1 N V\Jw M ��at� got ps-�ER ExP S�.• 16 , - ti c Workers' Compensation and Employer's Liability Policy UARD NorGUARD Insurance Company - A Stock Company I SURANCE Policy Number DOWC226291 I` Renewal of NEW ROU P NCCI No.[25844] Policy Information Page [1] Named Insured and Mailing Address Agency Douglas Mullen AUTOMATIC DATA PROCESSING Po Box 1274' INSURANCE AGENCY, INC. Marstons Mills, MA 02648 1 ADP Boulevard i Roseland, NJ 07068 Agency Code: NJADPI11 i Federal Employer's ID -20-8210838 Insured is Individual I Locations on Policy (1-2) 87 Hickory Hill Circle , Osterville, MA 02655 (04/12/2011 - 04/12/2012) [2] Policy Period From April 12, 2011 to April 12, 2012, 12:01 AM, standard time at the insured mailing address. [3] Coverage A. Workers' Compensation Insurance - Part One of this policy applies to the Workers' Compensation Law of the following states: Massachusetts B. Employer's Liability Insurance - Part Two of this policy applies to work in each of the states listed in item [3]A. The limits of our liability under Part Two are: Bodily Injury by Accident - each accident $100,000 Bodily Injury by Disease - each employee $100,000 Bodily Injury by Disease - policy limit $500,000 C. Other States Insurance - Part Three of this policy applies to all states, except any state listed in item [3]A. and the states of North Dakota, Ohio, Washington, and Wyoming. D. This policy includes these endorsements and schedules: See Extension of Information Page - Schedule of Forms [4] Premium `The Premium Basis and, therefore, the premium will be determined by our Manual of Rules, Classifications, Rates, and Rating Plans. All required information is subject to verification and change by audit. (Continued on another page) Total Estimated Policy Premium $ f 4,258 Total Surcharges/Assessments $ 266 Total Estimated Cost $ 4,524 INTERNAL USE DK Page 1 - Information Page MGA : DOWC226291 WC 000001A Date : 04/14/2011 MANOTE 16 South River Street•P.O. Box A-H•Wilkes-Barre, PA 18703-0020•www.guard.com tv CIA) z i ' �(n a 2 LO y� -rem n�5 fit- E - N C� x-.14i vL'�l u•'l� 5 �gyr�n<vp -M 1400 LOOK5l� ��j nil l LL i i �, � � t `'� � � x6,_ r. -,•, r., '-` r, � � �' ` - `� �. �;. _ � � �� L'� �,. �" �� 5 �r � - -:,� ' _ •--. ,�-....-sue _. .._ GT".. . AV •. � � - � •- ... !/.C�iETA?ELF`�. ""''- i.- 2Z . SANK �•�• _... _. Eke�- �qs ryL '•� .✓' /�' ' 109 �-,� _ '�'•'�', TIC, '''9:.fi` ..•... .../ ., � j,y• V i " ut n �) 3 .�EL� � �� OJ•L K. ST,-QA-4 - vO /l%L 4i'ST RIP, tr/e / 1 f?DO?/b,�,ryL .Pqv ` ! Ot/ La2o TO. f • Fg �D�E CF.t-XiSi, PAGc rye � - ••'� Og // D �00 S�aoS s,S TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map U yJ Parcel c)C)-5' Application # C) I t (0(0) Health Division Date Issued `� 1 Conservation Division �� 9A Application Fee S� Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board ^ Historic - OKH Preservation / Hyannis Project Street Address 2 N Z (,L A A5AE-&L. Ct)UE Village (_0TV T Owner t?FTere 1?1L%C(n0&K I Address .5AMf-- Alr2 PtoVC Telephone l o IV Permit Request But 1M S>pr(f cAt e dfF o ext 5T1� 12 EfAc q2 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation, 00 00 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family 0`_ 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 :1 `; Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other .P a Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal trove: O 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) Nand oL2 MyLLEde( Telephone Number 13'7- U9A Address Ft), Fox t'Z7N License # 15 lgIS AAA&Si-bAJS M)L,V5 AA4 02(oq Home Improvement Contractor# TWNo? Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 3&&5TA3L,& -M A-A)5-F� A) SIGNATURE (/tom- DATE Ir FOR OFFICIAL USE ONLY APPLICATION#o r ' DATE-ISSUED MAP/PARCEL NO. f " ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME r INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL ' GAS: ROUGH FINAL _ FINAL BUILDING DATE-CL'`OSED'OUT ASSOCIATION_ PLAN NO.- ' � r The Commonwealth of Massachusetts ( ,^ Department of Industrial Accidents Office of Investigations 'Y 600 Washington Street t t�i Boston MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): u L(_ca Address: Q t). gox 177 N City/State/Zip:NVV_,STV oV5 M J L L`z Phone #: SD��737 3 LEI a( Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ElI'am a general contractor and I 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2. am a sole proprietor or partner- listed on the attached sheet. t 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additid'ns 3.❑ I am a homeowner doing all work right of exemption per MGL 1 LEI Plumbing repairs or additions myself. [No workers' comp. c. 152, §](4), and.we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.[ ther comp. insurance required.] *Any applicant that checks box#I 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic. #: Expiration Date: , Job 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 ce9C.1 nder th pains and penalties of perjury that the information provided above is true and correct. Si nature: Date: Phone#: 6o9_- 73 7-- S Z41 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#: 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 in 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 empfoyment be-deemed to be an employer." MGL chapter 152; §25C(6)also states that"every state or local licensing agency shall'withbold'the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractors)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple 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. 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 leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, .please do not hesitate to give us a,call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts' Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 5-26-05 Fax # 617-727-7749 www.mass.gov/dia trti Town of Barnstable Regulatory Services RARNsrAsM v Muea �* Thomas F. Geiler,Director Building Division Tom Perry,Building C6mmissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I J (L UZk , as Owner of the subject.property hereby authorize o U b RU LL" to act on my behalf, in all matters relative to work authorized by this building permit application for. 2A Z- LC.A-MS RO— Cd 4 f X-IC> CoT0'1'T— (Add ess of rob) 3 l7 i f Signature of Date Pnnt Name If Property Owner is applying for permit please complete:the Homeowners License Exemption Form on the reverse side. i Town of Barnstable �0?THt rp�� Regulatoty Services swxrisreatE Thomas F. Geiler, Director KASSt659' Building Division PrFD �a Tom Perry, Building Commissioner 200 Mairi.Sireet, Hyannis,MA.02601 vrww.town.barnstable.ma.us Office: S08-862-4038 Fax: S08-790-6230 HOMEOWNER LICENSE EXEMPTTON Please Print DATE:. JOB LOCATION: number street village "HOMF,OWNER": name home phone# work phone# CURRENT MAILLNG 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. DEk'IT'TTION OF HOME01V ER 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 siructures accessory to such use and/or farm structures. A person who constricts 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 be/she shall be responsible for all such work performed under the building permit. (Section 109.L 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 be/sbe.will comply with said procedures and requirements. Signatbre of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction'Control. HOMEOWNER'S EXEMPTION .The Code states that: "Any homeowner performing work for which a building pemdt is required shall be exempt from the provisions of this section .(Sectian 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a pc son(s)for hire to do such work,that succh Homeowner shall act as supervisor." 1vlany homeowners who use this excmpdon•are unaware that they an assuming the responsibi)idcs of a supervisor(see Appendix Q. Rules&Rcglrlations 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 Supesor. The homeowner acting as Supervisor is ultimately responstble. rvi To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the bomcowvncr certify that hcJshe understands the responnbili6cs of a Supervisor. On the last page of this issue is a form currently used by several towns.. You may care t amend and adopt such a form/ccrtification for use in your community. Beard of Buildin<Re=ui lions and St.. ter£ >• P J j) t_ Lie(n5�pi.o[ ti aji'un �aii(I for Il.divFdul use itn"s_ .140 IE 11".PROVEMENT WCNTPAGI"Old 'r i a!nt fhc e�pr��*er [s rt�..lf fort)t eturn to: v tiegistrat�n 9383^08 t oa�[1 of beul[ic nid St^ndards ric A slibu[ton V:a:,e Plm-1301 Expiration`. 3/27J 0-11 Tr#.- "311 .; [ibs on,i\Isi.l[2103 Ty GBA I :°AULLEN BUILplt4G&REMODELING . . i DOUGLAS MULLEN YARt�ACU?i'1, M/f 0L673 d u; ?int `,lid tivitl[oi[1 Signature - :. A e. .ns6i,...T.j gr g 117assacbusctts- Department of Public Saret, Buil(-in.l _ ..� 7•Re�ulations�itnd Stand:u'(l ` Cdristruction Su �rVi5or 'License ue risk;'-ic *$j995 Restricted to 00 �- ... :p•(. - DOUGLAS W MULLEN 87 HICKORY HILL CIR OSTERVILLE, MA 02655 Expiration: 1/23/2012 I ('unuuissiuncr Tr#: 16801 i HIC Registration Complaints Page 1 of 1 The Official Website of the Office of Consumer Affairs&Business Regulation(OCABR) Mass.Gov Consumer Affairs and Business Regulation Home>Consumer> Housing Information> Home Improvement Contractor Program > HIC Registration Complaints Registration P 138368 Registrant MULLEN BUILDING&REMODELING Name DOUGLAS MULLEN Address P.O.BOX 1274 City,State,Zip MARSTONSMILL,MA,02648 Expiration Date 3/27/2013 Status Current No complaints found for this registrant. You can also view arbitration and Guaranty Fund history. Back To Search ©2011 Commonwealth of Massachusetts http://db.state.ma.us/homeimprovement/IicdetaiIs.asp?txtSearchLN=38858 3/31/2011 P�Y6 C) {-6oTlfj6 Et ISTrf'c, z 1. q - a/f FQ 7 �s � ` � - `�XN ►�°5T 5 � L 5 £M 3 ftTr PA; I n r CERTIFY THAT THIS PLAN HP PREPARED IN CONFORMITY WIT RULES AND REGULATIONS OF REGISTERS OF DEEDS OF THE COMMONWEALTH OF MASSACHI Professional Land Surveyor COTUIT CLAMSHELL COVE ROAD L=9.2 9' 115.76' PARCEL ID. C� / A.M. 005-005 PETER M. PRYGOCKI & JOANN JOHNSON �c�e 242 CLAMSHELL COVE RD. �o COTUIT, MA. 02635 a� LC cr �oz�$� G NOSE a Y z �X�c�-\N pE E LO LONG H w 00 PARCEL a• A.M. 005- p ROBERT SL p SUSAN J. BC TOP OF 41 SPARHAW 14c LANDSCAPE MARSHFIELD, n j 3' WIDE PATH TIMBERS J �s°sm ti] m TOM OF N SPARTINA PATENS & MIXED GRASES. MHW=2.5 SPARTINA ALTE RNIFLORA _ ML W o op ®A .H c, ° y 8' x 8' GRATED pp�� PLATFORM EL. 5.3 j ORAKE • J CIVIL —+ Q No.0642 O �' SHOESTF►'//VG BAY00 ' Z-Z 20 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map � JV " Parcel ' QL: ` Application # Health Division Date Issued Conservation Division Application F9 Planning Dept. Permit Fee ` Date Definitive Plan Approved by Planning Board Y � �`'wn®•az Historic - OKH Preservation / Hyannis Q /ry ri Project Street Address P �; Village G�7 V� `� Y 4cD _ f Owner P&_*70 C4'-' Address Telephone 02)y 7,b0 - 617o Permit Request l7E:AA D 41 X65002 E* pe:r_� c>IV &-PQ-J 7--lnrk1 OV oT �t�(nJ'r. Tk/,5 7-"1- A/&vJ 'p44,0 NI-? 0,V i� / , )P � 5I—VI/67 k ��eck Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuatior ® 0 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: 0 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: 0 Gas ❑ Oil ❑ Electric ❑ Other Central Air: 0 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 0 Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name —D4 1/67 � Telephone Number 506--7_37-37 V 4 Address F'Ul. t3 Off'�7i�y License # °)�✓' /V1l-W5 6A4—' a?-,& Home Improvement Contractor# ��J 3& Worker's Compensation #ALL CONSTR G: ION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO iWiv - TKAN i. I 5 o.U SIGNATURE DATE F S ,ww f � ` t FOR OFFICIA_L USE ONLY s. s APPLICATION# DATE.ISSUED v=+ r MAP/`PARCELNO. k, -ADDRESS_ - VILLAGE I. ` OWNER DATE OF INSPECTION: I, DATION: � Slc ilk 0� !0 p �oiL cA` FRAME INSULATION_�`�i. �=3 T i { 1 • S 1 ' FIREPLACE j ELECTRICAL: ROUGH FINAL ` PLUMBING: ROUGH FINAL GAS GAT . ROUGH'Rv-A�,,":__ FINAL" k � - ) j`FINAL BU:I.LD.INGu' � w_l a '� �O/ZRC4 4 E_ DATE CLOSED OUT ASSOCIATION PLAN NO. f i - '. The Commonwealth of Massachusetts Department of Industrial Accidents r' Office of Investigations 600 Washington Street Boston, MA 02111 www,mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information I/ � ) Please Print Legibly Name (Business/Organization/Individual): 00 f/��lr/ —� Address: 'O, -60X 1`777 q City/State/Zip: %DA11F A41 L41-7 AAA Phone #: S�7�y3�`r� Are you an employer?-Check the appropriate box: Type of project (required): ].❑ I am a employer with 4. ❑ I am a general contractor and I mp7oyees(full and/or part-tirhe). 6 ❑ New construction * have'hired the sub-contractors.. listed on the attached sheet. 7. ❑ Remodeling 2.I� 1 am a sole proprietor.or partner- ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition No workers' comp. insurance comp. insurance. required.) 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions officers have exercised their 1 I.[] Plumbing repairs or additions 3.❑ I am a homeowner doing all work 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• ther J7t� - comp.insurance required.] 4Any applicant that checks box#) must also fill out the section below showing their workers'compensation policy in formation. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContraetors that cheek this box must attached an additional sheet showing the name of the sub-contractors and stale 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 jab site information. Insurance Company Name: Policy# or Self-ins. Lic. #: Expiration Date: Job 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 eery rider the pains and penalties ofperjury that the information provided abov is tr to and cbrreeL Si afore; r 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): I.Board of Health Z. Building Department 3. City/Town Clerk 4. Electrical Inspector 5, Plumbing Inspector 6. Other Contact Person: Phone#: Information and. Mstructzons Massachusetts GeneraJ Laws chapter 152 requires all employers to provide 4vorkcrs' 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 cogaged in a joint cnle prise, and including the legal representatives of a deceased employer, or Lbe receiver or Lrustce of a❑ individual, partnership, association or other legal entity, employing employees. Ho�.vevcr the nt of the owner of a dwelling house having ool more Lban three apartments and who resides therein, or the occupa dwelling house of another who employs persons to do maintenance, constriction or repair work on such dwelling house or on Lbe grounds or building appurtenant Lhereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states [bat "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 cnter,into any contract for theperfonnance ofpublic--Work until acceptable evidence ofcomplianec with the insurance requirements ofthis chaplerhave becnpresentcd to the contracting authority." Applicants Please fill out.lbe workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary,supply sub-coniraelor(s) name(s), address(es)and phone numbcr(s)along with their cerlificate(s) of insurance. Liirlilcd Liability Companies (LLC)or Limited Liability Partnerships(LLP)With no employers othC7 than the members or partners, are not required to carry workers' compensation insurance. If an LLC orLLP does have employccs, a policy is required. Be advised that this affidavil may be submitted to the Department of Industrial Accidents for confirmation ofinsurance coverage. Also be sure to sign and date th-e affi'daYA The affidavit should be returned to the city or town Lhal•thc 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 e,workers' compensation policy,please call the Department at the number listed beloy,�. Self-insured companies sbould enter tbeir 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 affidavil for you to fill out in the event the Office of Investigations bas Lo contact you regarding the appli cant. Please be sure to fill in the pcnnil/license number which will be used as a.rcference number. Ln addition,an applicant that must submit multiple permit/Licensc applications in any given year, need only submit one affidavit indicating current policy infnrmalion (if necessary)aid under"Job Site Address" the applieanlshould write"a)) locations in (city or _ town)."'A copy of the afdavit that has been officially stamped or marked by Lhc city or town nay be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavi Dust be filled �ti t each year. Where a home owner or citizen is obtaining a license or permit not related to any bLiSineSStnr commcrci a I venture (i,e. a dog license of permit to burn leaves etc.) said person is NOT required to complete Ibis afidavil. The Office of Invesligalions wou e o t �rkpun��a�vacoo,"'rat'nn and should youhaye any questions, please do not bcsiLaie to give us a call. The DeparLmcnt's'address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 021 l l Te). # 617-727-4900 ext 406'or 1-877-MASSAFE Fax # 617-727-7749 Revised 1-24-07 www.tnass.gov/dia I I Towns of Barnstable Regulatory Services BA LX9'rABLY- v ' MAB& Thomas F. Geiler,Director �'Eo►. '` Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us office: 509-862-4039 Fax: 508-790-6230 Property Owner Must Complete and Sign.Thds Section If Using A Builder as Owner of the subject.property hereby authorize u LL-L&A-1 to act on my behalf, La all matters relative to work authorized by this building permit application for. (Address of Job) J 1 Signature of Owner Date Print Dame If Property Owner is applying for permit please.complete.the Homeowners License Exemption Form on the reverse side. Q:FORMS:o WNERPERMTSSION Town of Barnstable Y� pp THE r°lsy o Regul'atoty Services utuNsrxsLE% Thomas F. Geiler,Director HAss Building Division PrEn ►. Tom Perry, B tti'lding Commissioner 200 Main.StrcetHyannis, MA.02601 www.town.barnstable-ma.us Office: 508-862-4039 Fax: 508-790-6230 IiOhEEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# R ti CURRENT MAILING ADDRESS: city/town stag zip code 7bc current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and IF to allow homeowners to engage an individual for hire who does not possess a license,Provided that the owner acts as Supervisor_ f DEFIh'MON OR 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 constrgcts more than one home in a two-year period shall not be considered a bomeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be responsib)e 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.be/shc understands the Town of Barnstable Building Department minirnurn inspaction procedures and requirements and that he/she will comply with said procedures and requirements. Signatisrc of Homcowncr 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. + HOMBO WNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is rcquircd shall be exempt from the provisions of this section.(Secdon 109.).1 -Licensing of construction Supervisors);provided that if the homeovymcr argages a peson(s)for hire to do such work that such Homeowner shall act as supervisor." lriany homcowntas who use this rxcmption are unaware that they are assuming the responsibilities of a supervisor(sec Appendix Q, Rulcs&Regulations for Licensing Construction Supervisors,Scction 2.15) This lack ofawanencss bficn results in serious problems,particularly when the homeowner hires unlicensed parsons. In this case,our Board cannot proceed against the unlicensed person as it Wrould with a licensed Supervisor. The-horhrowncr acting as Supervisor is ultimate)y responsible. To ensue that the homeowner is M)y aware of hisAcr responsibilities,many communitics require, as part of the permit application., that the homeowner certify that hdshe underaands the responsibilities of a Supervisor. On the last page of this issue is a form eurrent)y used by several towns. You may care t amend and adopt such`a fomr/ccrtification for use in your community. t Q:for rrta:homcczcrrtpt f o �A '. t.. `\ Board of Bueldin .lteeuiaiiuns and Si::r ra1`Fi.4 :.� Lic(:nse or egi;t!stion v.tlid for individul use i,n HOME IMPROVEMENT CONTRACTOR I erai tlic exf�ii-atieP.date. If foai'.1 return to: -tRoard of Buildiab Rcr' l t'ions and St^ndards Registratiaii: 138368 One Ashburton P!^.e Pm.1301 Expirtigii: 3/? F 7 G11 TO. �.1:.'�g_ 2 13i�s+.on,I•In..� 108 Ts pe: GBA MULLEWBUILD•ING&REMODELING • • 1 OLIGLAS MULENL C '•�� 'r 5u ,OBBY LN i YARMCt Ti ,lVIA g2673 Adri ust, -NlassachuscUS - Department of Public Safety ?4 Board.of Building Rekulati,urs ant Standard' Construction Supervisor License License: CS; 81995 " Restricted to: 00 DOUGLAS W MULLEN "•,iJ 87 HICKORY HILL CIR OSTERVILLE, MA 02655 Expiration: 1/23/2012 ('•nnmissi mcr Tr#: 16801 :i ,- 516 t h 5 TO 'rVM-S ;. G 't��J`• ' v r � � r 41 ,.. w lilt r --......._. ....r. ....-.. .--r-! 77 r4 ` TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map ��•� Parcel �� {;Application ` t... Health Division "Date Issued Conservation Division 1��L S�3 - y � 121 Application Fee Planning Dept: Permit Fee: Date Definitive,Plan Approved by Planning Board Historic - OKH Preservation/Hyannis Project Street AddressZ Village 1- Owner Address Telephone41 Permit Request Square feet: 1 st floor: existing proposed '2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay l Construction Type Project Valuation � yp 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 If\ Number 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: 0 Yes ❑ No Q Detached garage: ❑existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: 0 existing 0 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 VA, Proposed Use - ' L/ APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name -!/Z�'�C�� i� Telephone Number Address R _P� License# c%JOql::20 C/Zc ' 1�1L� IVA �Home Improvement Contractor# � Worker's Compensation #i�AUB&70,,1c2,V 16b ALL CONSTRUCTION DEBRE RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE ' DATE FOR OFFICIAL USE ONLY APPLICATION# 4 e' r DATE ISSUED ' MAP/PARCEL N0. f j ADDRESS r' Y VILLAGE OWNER DATE OF INSPECTION: r FOUNDATION FRAME INSULATION - -FIREPLACE Y ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL .. I j GAS: ROUGH FINAL FINAL BUILDING _ ! DATE CLOSED OUT r ASSOCIATION PLAN NO. - , The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): &Z,G Address: City/State/Zip: %� d Phone #: ��V2 794 Are you an employer? Check the appropriate box: Type of project(required): 1.9 —1 am a employer with 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 working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance. required.] 5. ❑ We are a corporation and its 1.0.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I I.❑ 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 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: �� Policy#or Self-ins. Lic.#: /dzIVIM7__3 Kd 7/n� Expiration Date: i Job Site Address:�7�L J�crxjC T7K City/State/Zip: CCo—ib f?— 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify,under the p s e aloes of perjury that the information provided above is rue and correct. Si ature: Date: Phone#: c Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: �3/22/2011 07:50 FAX 5085635587 MURRAY&MACDONALD 12001/001 RightFax W3-2 3/22/2011 7:08:50 AM PACE 2/002 Fax Server ■ ACORD. CERTIFICATE OF LIABILITY INSURANCE oa�22no11 THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 71413 CERTIFICATE OF INSURANCE DOES NOTCONSTITUTE A CONTRACT BETWEEN THE ISSUING IN9URER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANTI II the cerUfloate holder Is en ADDITIONAL INSURED,the P0116000 must be endorsed, If SUBROOA71ON 19 WAIVED,■ubleet to the teTte end oond@lone of the poloy,oertdn pollole$nley require Arid.dersennenL A steterneht on this cardflode does not conler right$to the oerdfloate holder in Ilou of mmh erdoroomerd(s). PRODUCER CONTACT NAME: PHONE FAX MURRAY&MACDONALD INS (A/C,No,Em): FAX 550 MACARTHUR BLVD EMAIL (MC,No): ADDRESS: BOURNE,MA 02532 PRODUCER CUSTOMER ID a: 277XS INSURER(S)AFFORDING COVERAGE NAIC a INSURED INSURER A: TRAN•ELERS D MENZAT•Y COMPANY INSURER B: GILMORE MARINE CONTRACTING INSURER C: P 0 BOX 586 INSURER D;INSURER E: COTUIT,]41A 02635 INSURERF: COVERAGES CERTIFICATE NUMBER; REVRIWMNUMBER: TWO le YO CERTIFY THAT THE POUCIGO OF INSURANCE LISTED BELOW HAVG 8EIN 189UEDTOTHE INBUREO NAMED ABOVE FOR THE POucV PERIOD INDICATED. NOTWTTHBTANDINC ANY REQUIREMENT,TERM OR CONDITION OF ANV CONTRACT OR OTHER DOCUMENT WITH RE9PECT TO WHICH THIS CrWnFI1147E MAY BE IBDUGD OR MAY PERTAIN, THE INSURANCE AFFOROED BY TWO POUCIEO OEOCRIDED KREIN ID OUBJECT TO ALL THE TO WAR,EXCLU810Ne AND CONO(TIONS O►OUCH POUCI�a. LIMITS SHOWN NIAV HAVE oelN RODUCED BY PAID CLAWS. INDR ADDLBUBR POLICY EFF DATE POLICY EXP DATE LTA TYPEOFINOURANCE [NOR WVD POUCYNUMBRR (Men001yYYY) (MpADDIYYYY) UMITO GENERAL LIABILITY EACH OCCURRENCE COMMERCIAL GENERAL LIABILITY CLAIMS MADE OCCUR. DAMAGE TO RENTED $PREMISES(Ee aoburloneo) MED EXP(Any one person) g OEN'L AGGREGATE LIMB APPLIEy PER! PERSONAL 8A IADj INJURY $ OENERALAOORE-DATE $ POLICY PROJECT LOC PRODUCTS-COMP/OP AOCr $ AUTOMOBILE LIABILITY ANY AUTO COMBINED SIN OL E $ LIMIT(Es ecdde t ALL OWNED AUTOS BODILY INJURY i g 9CHEDULEAUT09 HIRED AUTOS (Per pereon) BODILY INJURY $ NON-OWNED AUT09 (Por Docldorb) PROPERTY DAMAGE S (Per sceldonl) i UMBRELLA LIAO OCCUR EACHOCCIIRRE GE S EXCESS LIAR CLAIMS-MADE DEDUCTIBLE AOOREQA)N ( S RETENTION$ j $ WORKER'S COMPENSATION AND WC STATUTORY 1lbt Ta 07►IER EMPLOYER'S LIABILITY YIN US-0702r►IWIO 07/01/2010 07A)1R011 E.L EACH ACC'ID T $ 11000,000 ANY PROPERITOWPARTN5MXGCUTIVE N OF•FICEwMEMBER EXCW DEO? EL.DISEASE•EA EMPLOYEE $ 11000,000 (nundmery In NH) II Toe,0000e Undv E.L.OI96ASE•PO ICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLESIRESTRICTIONS/SPECIAL ITEMS THLS REPLACES ANY FR101t CBRTIAICXM ISSUED TO'1-HECERMCAT-2HOLDMZ APFECPWG WORtCFRS COMP COV3MAOP I CERTIFICATE HOLDER CANCELLATION I TOWN OF BARNSTABLE BUa DING DEFT SHOULD ANY OF THE ABOVE OESC 611,POLIC ES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,N TICE WILL BE DELIVERED IN ACCORDANCE 200 MAW STREET WITH THE POLICY PROVISIONS, I AUTHORIZED REPRESENTATIVE 14YANTITS.MA 02601 Charles 7 Clark ACORD 25(2000100) 1081-2009 ACORD CORiO 11ATION. All rlght9 maerved. I i I Town of Barnstable Regulatory Services s s,►MASS. = Thomas F.Geller,Director MASS. Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-8624038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section I£Using A Builder _:..;as.0uvner..of the.subject property- to-:act ._......._.. :: hereby authorize on my.b eb A. in all matters relative to work authorized-by-this building permit-application-for: Z (Address of job) Signature of Owner. Date Print Name Massachusetts- Department of Public Safet Board of Building Reguldttiiins•and Standards 4' Construction Supervisor License License- CS 68433 j l tistricted to: 00 OEORGE.IZ. OILLM0RE PO BOX 940 'COTUIT, MA 02635 = Expiration: 6/10/2012 ('ununixsiinier' ' Tr#: 26853 -7/. Office of Consumer Affairs 8;B siness Regulation HOME IMPROVEMENT CONTRACTOR Registration: ,07,23494 Type:. i(. 'k Expiration: 2/`-2W,,013 Private Corporatio Gillmore Marine Cr; r5c /77�� George Gillmore �� _ . I 37 Bowdoin Rd 1 c ?`. M'aslipee,MA 02649 `�,y Undersecretary Restricted to: 00 00- Unrestricted •` 1G-1 2 Family Homes , Failure to possess a current edition of the Massachusetts State Bdil'ding'Code is cause for revocation,"f this'license. Refer to: WWW.Mass.Gov/DPS i License or registration valid for individul use only before the expiration date. If found return to: Office of Consumer Affairs and Business Regulation �. 10 Park Plaza-Suite 5170 Boston,MA 02116 is t valid hout signature r 1 f J Pie eommmumaM of AfzwaAwetb S No. 12850 .Whereas, Peter M. Prygocki & Joann Johnson of--Barnstable--in the County of--Barnstable-- and Commonwealth aforesaid, has applied to the Department of Environmental Protection for license to -- construct and maintain a pier and one (1) pulley pile-- and has submitted plans of the same; and whereas due notice of said application,A-e€ 0 R pIaGG 4xoa r& i@ g t i, has been given, as required by law, to the -- Town Council -- N of the--Town of Barnstable. -- :u if NOW; said Department, having heard all parties desiring to be heard, and having fully considered said•application,hereby, subject to the approval of the Governor, authorizes and licenses the said -- Peter M. Prygocki & Joann Johnson--, subject to the provisions of the ninety-first chapter of the General Laws, and of all laws which are or may be in force applicable thereto, to -- construct and maintain a pier and one (1)pulley pile-- J in and over the waters of-- Shoestring Bay--at'-- 242 Clamshell Cove Road-- in the -- Town of Barnstable(Cotuit) --and in accordance with the locations shown and details indicated on the accompanying DEP License Plan No. 12850 (3 sheets). C License No. 12850 Page 2 The structures hereby authorized shall be limited to the following use(s): noncommercial docking and boating access.to navigable waters. This license will expire thirty(30)years from the date of license issuance. By written request of the licensee for an amendment, the Department may grant a renewal for the term of years not to exceed that authorized in the original license. Special Waterways Conditions: In accordance with any license condition, easement, or other public right of lateral passage that exists in the area of the subject property lying between the high and low water marks, the Licensee shall allow the public in the exercise of such rights to pass freely over or under all structures within such intertidal area. Accordingly, the Licensee shall place and maintain, in good repair, a public access sign on both the northerly and southerly sides of the pier authorized herein, adjacent to the mean high water shoreline. Said signs, designed in accordance with the signage specifications provided by the Department, attached hereto, shall be posted immediately upon the completion of construction. Nothing in this condition shall be construed as preventing the Licensee from excluding the public from portions of said structure(s) or property not intended for lateral passage. In partial compensation for private use of structures on tidelands of the Commonwealth, which interferes with the rights of the public to use such lands, the Licensee shall allow the public to pass on foot, for any purpose and from dawn to dusk, within the area of the subject wproperty lying seaward of the high water mark. This condition shall not be construed to prevent the Licensee from taking reasonable measures to discourage unlawful activities by users of the area(s) intended for public passage, including but not limited to trespassing on the adjacent private areas and deposit of refuse of any kind or nature in the water or on the shore. Further, the exercise by the public of free on-foot passage in accordance with this condition shall be considered a permitted use to which the limited liability provisions of M.G.L. c.21, s.17c apply. No dredging(including, but not limited to the effects of prop wash)is permitted herein. Motorized vessels shall not be used or berthed at the pier or platform. All work authorized herein shall be completed within five (5) years of the date of license issuance. Said construction period may be extended by the Department for one or more one year periods without public notice, provided that the Applicant submits to the Department, thirty(30) days prior to the expiration of said construction period, a written request to extend the period and provides an adequate justification for said extension. Within sixty (60) days of completion of the licensed project, the Licensee shall request, in writing, that the Department issue a Certificate of Compliance in accordance with 310 .CMR 9.19. The request shall be accompanied by a certification by a registered professional engineer licensed in the Commonwealth that the project was completed in accordance with the License. Please see page 3 for additional conditions to this license. Duplicate of said plan, number 12850 is on file in the office of said Department, and original of said plan accompanies this License, and is to be referred to as a part hereof. j License No. 12850 Page 3 STANDARD WATERWAYS LICENSE CONDITIONS 1. Acceptance of this Waterways License shall constitute an agreement by the Licensee to conform with all terms and conditions stated herein. 2. This License is granted upon the express condition that any and all other applicable authorizations necessitated due to the provisions hereof'shall be secured by the Licensee prior to the commencement of any activity or use authorized pursuant to this License. 3. Any change in use or any substantial structural alteration of any.structure or fill authorized herein shall require the issuance by the Department of a new Waterways License in accordance with the provisions and procedures established in Chapter 91 of the Massachusetts General Laws. Any unauthorized substantial change in use or unauthorized substantial structural alteration of any structure or fill authorized herein shall render this Waterways License void. 4. This Waterways License shall be revocable by the Department for noncompliance with the terms and conditions set forth herein. This license may be revoked after the Department has given written notice of the alleged noncompliance to the Licensee and those persons who have filed a written request for such notice with the Department and afforded them a reasonable opportunity to correct said noncompliance. Failure to correct said noncompliance after the issuance of a written notice by the Department shall render this Waterways License void and the Commonwealth may proceed to remove or cause removal of any structure or fill authorized herein at the expense of the Licensee, its successors and assigns as an unauthorized and unlawful structure and/or fill. 5. The structures and/or fill authorized herein shall be maintained in good repair and in accordance with the terms and conditions stated.herein and the details indicated on the accompanying license plans. 6. Nothing in this Waterways License shall be construed as authorizing encroachment in,on or over property not owned or controlled by the Licensee,except with the written consent of the owner or owners thereof. 7. This Waterways License is granted subject to all applicable Federal, State, County, and Municipal laws, ordinances and regulations including..but not limited to a valid final Order of Conditions issued pursuant to the Wetlands Protection Act,G.L.Chapter 131,s.40. 8. This Waterways License is granted upon the express condition that the use of the structures and/or fill authorized hereby shall be in strict conformance with all applicable requirements and authorizations of the DEP, Division of Water Pollution Control. 9. This License authorizes structure(s)and/or fill on: X Private Tidelands. In accordance with the public easement that exists by law on private tidelands,the licensee shall allow the public to use and to pass freely upon the area of the subject property lying between the high and low water marks,for the purposes of fishing,fowling,navigation,and the natural derivatives thereof. X Commonwealth Tidelands. The Licensee shall not restrict the public's right to use and to pass freely;for any lawful purpose, upon lands lying seaward of the low water mark. Said lands are held in trust by the Commonwealth for the benefit of the public. a Great Pond of the Commonwealth. The Licensee shall not restrict the public's right to use and to pass freely upon lands lying seaward of the high water mark for any lawful purpose. Navigable River and Streams. The Licensee shall not restrict the public's right to use and to pass freely, for any lawful purpose,in the waterway. No restriction on the exercise of these public rights shall be imposed unless otherwise expressly provided in this license. 10. Unless otherwise expressly provided by this license,the licensee shall not limit the hours of availability of any areas of the subject property designated for public passage,nor place any gates, fences, or other structures on such areas in a manner that would impede or.discourage the free flow of pedestrian movement thereon. License No. 12850 Page 4 The amount of tide-water displaced by the work hereby authorized has been ascertained by said Department, and compensation thereof has been made by the said -- Peter M. Prygocki &Joann Johnson--by paying into the Treasury of the Commonwealth-- two dollars and zero cents ($2.00) -- for each cubic yard so.displaced,being the amount hereby assessed by said Department. (0 cy=$ 0.00) Nothing in this License shall be so construed as to impair the legal rights of any person. This License shall be void unless the same and the accompanying plan are recorded within 60 days from the date hereof, in the Registry of Deeds for the County of Barnstable. IN WITNESS WHEREAS, said Department of Environmental Protection have hereunto set their hands this 21 st day of October in the year two thousand ten. I Chief - ?, /Vrogram Department of Environmental Protection Commissioner THE COMMONWEALTH OF MASSACHUSETTS This license is approved in consideration of the payment into the treasury of the Commonwealth by the said--Peter M..Prygocki&Joann Johnson of the further sum of--three hundred three dollars and zero cents($ 303.00) =- the amount determined by the Governor as a just and equitable charge for rights and privileges hereby granted in the land of the Commonwealth. BOSTON, Approved by the Governor. Governor L.v vC IRUNU ROAD L=9.2 9 115.76' PARCEL ID: /�j LOCUS A.M. 005-005 0 PETER M. PRYGOCKI & <v/fie `O JOANN JOHNSON QQ?� N 242.CLAMSHELL COVE RD. Q 00 Qo COTUIT, MA. 02635 �� OPPONE.. T BAY w0 a: E LOCUS MAP NOv a- Q z q a to¢x0: t�X� pEGK C)� '% E� R Q 0`0 GANG i ) 00 La PARCEL ID: O A.M. 005-004 TOP ROBERT J. & F $LOp f SUSAN J. BOTHWELL �p TOP OF 41 SPARHAWK PATH 3' WIDE PATH LANDSCAPE MARSHFIELD; MA. 02050 CJOXTIMBERS z- of - STEPS m O�.IOM OF ANK SPARTINA PA7FNs & MIXED GRASES HW=2.5 S♦AR77NA A0ERNIFLORq a �S PN�\N3 3 M • • F MAR. H Lu 8' x 8' GRATED �P�OE PLATFORM EL. 5.3' OF Mqs N FtOSERT A.. �G J DRAKE Q d CI416 �. 142 O sHo�sr,�iNc U/`1 Y 13SEP�� 00 <c _ 0 20 40 I ]Elm SCALE: 1."=40' PLANS ACCOMPANYING PETITION OF ELEVATIONS ARE BASED ON M.L.W. PETER M. PRYGOCKI & J O A N N J O H N S O N LICENSE PLAN NO. 1 2B 5 TO CONSTRUCT AND MAINTAIN A PIER Approved by Department Of EnvironmenW Protect-ion IN SHOESTRING BAY BARNSTABLE (COTUIT), MA. of Massachusetts , `gyp DATE: FEB. 3, 2010 SHEET 1 OF 3 A _ w PROPOSED z STEPS a. 0 ^) a 4 s BOTTOM w 4. a OF BANK rZ 2 ® SPARTINA PATENS & M1XED GRASES .� own= MHW=2.5 m masm ammm SPARTINA AL 2.3 © e TERNIFLpRA 0 • D O\\,G —0.5 —0.4 e ® ® EDGE OF MARSH LPG. 5� ML a 0 � -0.8 - -0 8 O L 8' x 8' GRATED OARS - PLATFORM .EL. 5.3' —1.5 \�Q•� —1.4 15 —1.4 1.3 —1.0 8" DIA. PULLY PILE —2.0 —1.6 —1.6 —1.6 —1.7 —1.5 —1.7 —1.6 -1.6 —1.7 —1.7 —1.7 LICENSE PLAW W. 12 9 5 O Ap�J�ppp/��roved by Department of Environmer�l n —�8 —1.7 —1.7: —1..6 —1.8 —1.8 PLANS ACCOMPANYING PETITION OF PETER. M. PRYGOCKI & JOANN JOHNSON � RTA. DW<€ TO CONSTRUCT AND MAINTAIN A PIER IN SHOESTRING BAY No.44642 o y BARNSTABLE (COTUIT), MA. f AL 0 10 20 )AT1fiE FEcB. 3, 2010 SCALE: 1"=2 _ g ��!,!.•i� `�k '� �-',®.� I. . '...� � cG8 .c:aP PYN'.�1 r 1-�.�b�"�' �i.'��L' ., 'rY ?O �. 'IN Flo ..... .r......,�. 1r) . . .LJ Q _I �IJ 8" DIA TIMBER ` I W 'W PILES 11' O.C. (TYP) i O 4'_0l, 2"XV DECKING z WITH 1" SPACING(TYP) I oz II .o Sri cr- ' CL_a_I W 4, ;"X8"STRINGERS "O.C.(TYP) PIER ELEV. 5.3' Y. I awl i a Q(n W Q .D EACH"SIDE OF P LE(rM) _ � I \ I 20d GALV. NAILS(TYP) 2"X8"BRACING 0 Q 3 i ij AT ALL PILE BENTS(TYP) 15' MIN. OR.REFUSAL x PILE EMBEDMENT o I � J a ±I TYPICAL FI XED -1 PIER SECTION I I I (NOT TO SCALE) E j o � O � J aA CD — I� I LL � J I I o p w w IIwII � Q _j p O00 o x O- 00Li co } II II O Z W W \ W J J 2 IZ Q � cm_• Q U � QCS p 2 J V N VA OF 00 I I (.1 I CD ; A. O I ® _ DRAKE ix 0- 1N0.416L42 Q T P )ATE: FEE. 3 2010 sly Massachusetts Department of Environmental Protection Bureau of Resource Protectionl-;Wetlands MassDEP File Number: WPA Form 5 - Order of Conditions SE3- 4854 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 and § 237-1 to §.237-14 Town of Barnstable Code A. General Information Important: Barnstable When filling 1. From: Conservation Commission out forms on r }. the computer, 2. This issuance is for(check one): a. ® Order of Conditions b. ❑ Amended Order of Conditions use only the tab key to 3. To: Applicant: move your cursor-do not Peter Prygocki use the return Joann Johnson -- ke a.First Name b.Last Name' " i ren c.Organization 242 Clamshell Cove Road + Ir'I•i l i ,' u• �b;rl ' , ,r,;;; I „ , d.Mailing Address Cotuit MA , - - .02635 e.City/Town f.State '' g:Zip?Code 4. Property Owner(if different from applicant): a.First Name b.Last Name' ' L'` ,, � Itl ,"} 'i�71' :?+ 'I I•. .il,,,•111 rC�fEifF'I,`a ; �oFIHE rqk c.Organization enrlrisrnetE d.Mailing Address truss. � 1639. pTfDMAfA e:City/Town f.State " "'Ir' r g.Zip Code ` I 5. Project Location: 242 Clamshell Cove Road Cotuit a.Street Address b.Village 005 ' 005 c.Assessors Map Number d.Assessors Parcel Number Latitude and Longitude, If known: e.Latitude f.Longitude 6. Property recorded at the Registry of Deeds for(attach additional information if more than one parcel): Barnstable a.County b.Certificate Number(if registered land)/Plan/Lot# 22975 281 c.Book d.Page 7. Dates: November 10, 2009 December 1, 2009: DEC 1 4 2009 a.Date Notice of Intent Filed b.Date Public Hearing Closed c.Date of Issuance 8. Final Approved Plans and Other Documents (attach additional plan or document references as needed): Revised Site Plan a.Plan Title A. M.Wilson Associates, Inc. Robert A. Drake, P.E. b.Prepared By c.Signed and Stamped by December 2, 2009 1" =20' d.Final Revision Date e.Scale f.Additional Plan or Document Title g.Date wpaform5.doc- rev.2127/08 Barnstable revised 4/11/2008 Page 1 of 10 Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands MassDEP File Number: SE3 4854, WPA Form 5 - Order of Conditions,l Massachusetts Wetlands Protection Act M.G.L. c. 131, §400 and § 237-1 to § 237-14 Town of'Barnstable Code B. Findings W 1. Findings pursuant to the Massachusetts Wetlands Protection Act: Following the review of the above-referenced Notice of Intent and;based on4the°information provided in this application and presented at'the'public hearing, this Comrhission finds that the'arbds in which work is proposed is significant to the following interests of the Wetlands Protection Act. Check all that apply: a. ❑ Public Water Supply b. ® Land Containing Shellfish c. ® Prevention of Pollution d. El Private Water Supply e. ®liFisheries I;I Protection of Wildlife .Habitat i g. ❑ i` GroundwaterSuppIy h. ®�:�Storm Damage Prevention:i: ® Flood. 2. This Commission hereby finds the project,as proposed, is:(check one of the following boxes) Approved subject to: a. ® the following conditions which,are necessary in accordance with the performance standards set forth in the wetlands regulations. This Commission orders that all work.shall be performed in accordance with the Notice of Intent referenced above, the following Gleneral Conditions; and any other special conditions attached to this Order. To the extent that the following conditions'modify or differ from the plans, specifications, or other proposals submitted with the Notice of Intent, these conditions shall control. Denied because: l b. ❑ the proposed work cannot be conditioned to meet the performance standards set forth in the wetland regulations. Therefore,work on this project may not go forward unless and until a new Notice of Intent is submitted which provides measures which are adequate to protect these interests, and a final Order of Conditions is issued. A description of the performance standards which the proposed work cannot meet is attached to this Order. c. ❑ the information submitted by the applicant is not sufficient to describe the site, the work, or the effect of the work on the interests identified in the Wetlands Protection Act. Therefore, work on this project may not go forward unless and until a revised Notice of Intent is submitted which provides sufficient information and includes measures which are adequate to protect the Act's interests, and a final Order of Conditions is issued.A description of the specific information which is lacking and why it is necessary is attached to this Order as per 310 CMR 10.05(6)(c). Inland Resource Area Impacts: Check all that apply below. (For Approvals Only) 3. ❑ Buffer Zone Impacts: Shortest distance between limit of project disturbance and wetland boundary (if available) a.linear feet Resource Area Proposed Permitted Proposed Permitted Alteration Alteration Replacement Replacement 4. ❑ Bank a.linear feet b.linear feet c.linear feet d.linear feet 5. ❑ Bordering Vegetated Wetland a.square feet b.square feet c.square feet d.square feet 6. ❑ Land Under Waterbodies a.square feet b.square feet c.square feet d.square feet and Waterways e.c/y dredged f.c/y dredged wpaform5.doc• rev.2127/08 Barnstable revised 4/11/2008 Page 2 of 10 Massachusetts Department of Environmental Protection Bureau of Resource Protection = Wetlands i MassDEP File Number: WPA Form 5 - Order of'Conditions . .I . , s- E3- 4854 Massachusetts Wetlands Protection Act M.G.L. c. 131,;§40 and § 237-1. to § 237-14 Town of Barnstable Code B. Findings (cunt.) �- _� Resource Area Proposed Permitted Proposed Permitted Alteration Alteration(' Replacement Replacement 7. ❑ Bordering Land Subject to Flooding a.square feet b.square feet c.square feet d.square feet Cubic Feet Flood Storage e.cubic'feet f.cubic feet" `g.°'cubic feet" h.`cubic feet 8. ❑ Isolated Land.Subject to Flooding a.squdr`e feet b.square feet Cubic Feet Flood Storage c.cubic feet d.cubic feet e.cubic feet f.cubic feet 9. ❑ Riverfront area a.ibtal sq:feet b.total sq.feet ur Sq ft within 100 ft c.square feet d.square feet `e."square feet -f.square feet Sq ft between 100-200 ft g.square feet h.square feet i.square feet j.square feet Coastal Resource Area Impacts: Check-all that apply below. (For Approvals Only) 10. ❑ Designated Port Areas 'Indicate size under Land Under the Ocean, below 11. ❑ Land Under the Ocean !2,44;ds; 88 sh ;�,,�.• � I; eta �l"`1!: :; ,�' i-Irk ' •a.square feet b.square feet,.,. r u°rylr7 bto,t. :EC. :i;s .i c.c/y dredged d.c/y dredged 12. ❑ Barrier Beaches Indicate size under Coastal Beaches and/or Coastal Dunes below 1.74-ds; 64 sh 13. ® Coastal Beaches a.square feet b.square feet c.c/y nourishmt. d.c/y nourishmt. 14. ❑ Coastal Dunes a.sgdare feet b.square feet c.c/y nourishmt. d.c/y nourishmt. 15. ® Coastal Banks —75'x 4' maint a.linear feet b.linear feet 16. ❑ Rocky Intertidal Shores a.square feet b.square feet 17. ® Salt Marshes 1.05 ds 1 13.5 sh b.square feet c.square feet d.square feet 18. ❑ Land Under Salt Ponds a.square feet b.square feet c.c/y dredged d.c/y dredged 19. ❑ Land Containing Shellfish a.square feet b.square feet c.square feet d.square feet 20. ❑ Fish Runs Indicate size under Coastal Banks, inland Bank, Land Under the Ocean, and/or inland Land Under Waterbodies and Waterways, above a.c/y dredged b.c/y dredged 21. ® Land Subject to Coastal 265.5 Storm Flowage a.square feet b.square feet wpafonn5.doc• rev.2/27/08 Barnstable revised 4/11/2008 Page 3 of 10 w | . b ' |h t ��1� ' [ ,�� nr ��assachuse�s�De�a��ent.wf Environmental �oK�t��+i ��.m � ar ' ' '~~ ' - ^ ' EP Fiie N mbec BU�8U of Resource PP��OO -W�@OdS ��yxi� | ` ^ ' « �� 0��/�� ^� ^ ' -�� *��^�^��un� �hnUM� *.��~k ��^ ' . ~ ~ ^ ~ ~ " ~~~ ^^^ p~ ��" ~=~�"�/ o^ ��.~. .*�v�n~...�m ~^~� -~~- Massachusetts Wetlands Protection Act M.G.L. c. 131. 840 rotb6tion Act p' h ' | u, u n./h' n( | I. (only applicable to approved projects) r , ` m�|u/' 'J' � ', .`. /..p x » ol, 1"+ 1. Failure to complywith all conditions ��h U and other regu�tory nneasures. shoUb�deemedoau�ebi�e(�koorrnod�vthio {}rd��«t /��*' ~/ '�n|'ip�f'J' 2. The Order does not grant ' ' ' exclusive pr�U o aoa ; itdoosnotauthor�eany injury tophvoteproperty ori property rights.. anc |h(�' th-ir k,c/ /hhr U.t: � 3. This Order does' i� oU other opp|�ob|efadano[,state, dfkjoalb�atubeu. ordinances, by ��4 � ' �� '|;- ixd � zi ^ 'all 'be ! unless either ofthe following apply I J. Ii - the work - - '------nce— ~'~~x^'u project~~ provided for"''the Act; "" � b. the time for completionhaa been extended to a specified date more than than five ye6rs�from the date of issbance. If this Order is in"ie' ride'd't6'be'vaild"for-66're'than three years, the extension date and the special circumstances warranting the extended time period are set forth oso special condition in this Ordar� /.| `kr| / f. :"': \'" | 5. This Order may.be extended by the issuing authority for one or more periods of up to three years each | upon application to the issuing authotity,at least 30 days prior to the expiration date of the Order. 0. Any fill used in connection with this project ahaUbac|eanfiU. AnyfiUuhaUoonbainnubaoh. refuoo. rubbish, or debris, including but not limited to |unnbor, bhcko, plaster, wire, |oth, papar, cardboard, pipa. Unam, amhao, refhgenotoru, motor vehicles, or pads of any of the foregoing. 7. This Order is not final until all administrative appeal periods from this Order have elapsed, or if such an appeal has been taken, until all proceedings before the Department have been completed. 8. No work shall be undertaken until the Order has become final and then has been recorded in the Registry of Deeds or the Land Court for the district in which the land is located, within the chain of title of the affected property. In the case of recorded land, the Final Order shall also be noted in the Registry's Grantor Index under the name of the owner of the land upon which the proposed work is to be done. In the case of the registered land, the Final Order shall also be noted on the Land Court Certificate of Title of the owner of the land upon which the p aadvvorkiadonn. Thoranonjing information shall be submitted to this Conservation Comirri on the form at the end of this Order, which form must be stamped by the Registry of Deeds, prior to the commencement of work. } S. A sign shall be displayed ot the site not less then two square feet or more than three square feet in size bearing the words, ' � "Massachusetts Department of Environmental Protection" [or. ^MosoDEPl , Fi|eNumber 8E3-4854 . ^ t ^ Bamstable revised 4/11/2008 Page*mm / - � ILI) Massachusetts Department of Environmental Protection 3 ; Bureau of Resource Protection - Wetlands MassDEP File Number: WPA Form ,5 - Ord.er`of Conditions SE3="4854 Massachusetts Wetlands Protection Act M.G.L. c. 131, 1§40 and § 237-1 to § 237-14 Town of Barnstable Code C. General Conditions Under Massachusetts Wetlands Protection`Act 10. Where the Department of Environmental Protection is requested to issue a Superseding Order, the Conservation Commission shall be a party to all agency proceedings and hearings before MassDEP. 11. Upon completion'of the work described herein, the applicant shall submit a Request forCertificate of Compliance (WPA Form 8A)to the'Conservation Commission 12. The work shall conform to the plans and special conditions referenced in this order. l 13. Any change to the plans identified in Condition#12 above shall'reIduire'th"e applicant to"ingUire of the Conservation Commission in-writing whether the change is significant enough to require the filing of a new Notice of Intent. 14. The Agent or members of the Conservation Commission and the Department of Environ"m6ntal Protection shall have the right to enter and inspect the area subfect to this Order at reasonable hours to evaluate compliance with the conditions stated in this Order, and may require the submittal of any data deemed necessary by the Conservation Commission or Department for that�evaluation. 15. This Order of Conditions shall apply to any successor in interest or`successor in,co�nitrol of the property subject to this Order and to any contractor or other person performing work conditioned by this Order. 16. Prior to the start of work, and if the project involves work adjacent,rto.a Bordering IUegetaied Wetland, the boundary of the wetland in the vicinity of the proposed work area shall be marked by wooden stakes or flagging. Once in place, the wetland boundary markers shall be maintained until a Certificate of Compliance has been issued by the Conservation Commission. 17. All sedimentation barriers shall be maintained in good repair until all disturbed areas have been fully stabilized with vegetation or other means.At no time shall sediments be deposited in a wetland or water body. During construction, the applicant or his/her designee shall inspect the erosion controls on a daily basis and shall remove accumulated sediments as needed. The applicant shall immediately control any erosion problems that occur at the site and shall also immediately notify the Conservation Commission, which reserves the right to require additional erosion and/or damage prevention controls it may deem necessary. Sedimentation barriers shall serve as the limit of work unless another limit of work line has been approved by this Order. 18. The work associated with this Order is (i)❑ is not(2)® subject to the Massachusetts Stormwater Policy Standards. If the work is subject to the Stormwater Policy, the following conditions apply to this work and are incorporated into this Order: a) No work, including site preparation, land disturbance, construction and redevelopment, shall commence unless and until the construction period pollution prevention and erosion and sedimentation control plan required by Stormwater Standard 8 is approved in writing by the issuing authority. Until the site is fully stabilized, construction period erosion, sedimentation and pollution control measures and best management practices (BMPs)shall be implemented in accordance with the construction period pollution prevention and erosion and sedimentation control plan, and if applicable, the Stormwater Pollution Plan required by the National Discharge Elimination System Construction General Permit. wpaform5.doc- rev.2127/08 Barnstable revised 4/11/2008 Page 5 of 10 ri Massachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands MassDEP File Number: WPA Form 5 — Ord' ' ' of,Condition '`t ' '�''''�` "'s'E '' i' i I .rrw -� 3-,�854 Massachusetts Wetlands Protection Act M.G.L. c. 131,t§'0 ► ,i_rr 1,`!, and § 237-1 to '237-14 Town of Barnstable Code C. General Conditions Under Massachusetts Wetlands' Protection'ACt (cost.) 1 •r 1'. FI't ( r.f, 7r' ;' Irh ' IE ' b) No stormwater runoff may be discharged to the post-construction"stormwater'BMPs until written approval is received from the issuing authority. To request written approval, the"following must be submitted: illicit discharge compliance statement required by Stormwater Standard 10 and as-built plans signed and stamped by a registered professional engineer certifying'thelsite is fully stabilized; all construction period stormwater BMPs and any illicit discharges to the'stormwater management system have been removed; and all post-construction stormwater BMPs,were installed in accordance �r ; , with the plans (including all planting1f plans)approved by the issuingt authorf. ityi, an�.d have been inspected to ensure they are not damaged and will function properly. I c) Prior to requesting a Certificate of,Compliance, the responsible party(defined in General Condition 18(e))shall submit to the issuing authority an Operation and Maintenance(O &'M) Compliance Statement for the Stormwater BMPs. This Statement shall identify the,responsible party for implementing the Operation and Maintenance Plan and also,state that: 1. "Future responsible parties shall be notified in writing of their continuing legal responsibility to operate and maintain the stormwater management BMPs and implement the Pollution Prevention Plan; and 2. The Operation and Maintenance Plan for the stormwater BMPs is complete and will be implemented upon receipt of the Certificate." I , i. tfu -r •'t i,'; . 'r.l Ill ; ;.-( - d) Post-construction pollution prevention and source control shall be implemented in accordance with the long-term pollution prevention plan section of the approved Stormwater Report and, if applicable, the Stormwater Pollution Prevention Plan required by the,National,Discharge,Elimination System Multi-Sector General Permit. I ;it I r frr e) Unless and'until another party accepts responsibility, the issuing authority shall presume that the responsible party for maintain ing•each BMP is the landowner of the property oniv0ic.H the'BMP is located. To overcome this presumption, the landowner of the property must submit to the issuing - - - -authority a legally binding-agreement-acceptable-to the-issuing-authority-evidencing thatfanother entity has accepted responsibility for maintaining th the BMP, and that e proposed responsible party shall be treated as a permittee for purposes of implementing the requirements of Conditions 18(f) through 18(k)with respect to that BMP. Any failure of the proposed resporlsiOe'party to implement the requirements of Conditions 18(f)through 18(k)with respect to that BMP shall be a violation of the Order of Conditions or Certificate of Compliance. In the case of stormwater BMPs that are serving more than one lot, the legally binding agreement shall also identify the lots that will be serviced by the stormwater BMPs. A plan and easement deed that grants the responsible party access to perform the required operation and maintenance must be submitted along with the legally binding agreement. f) The responsible party shall operate and maintain all stormwater BMPs in accordance with the design plans,the Operation and Maintenance Plan section of the approved Stormwater Report, and the Massachusetts Stormwater Handbook. g) The responsible party shall: 1. Maintain an operation and maintenance log for the last three years including inspections, repairs, replacement and disposal (for disposal the log shall indicate the type of material and the disposal location); 2. Make this log available to MassDEP and the Conservation Commission upon request; and 3. Allow members and agents of the MassDEP and the Conservation Commission to enter and inspect the premises to evaluate and ensure that the responsible party complies with the Operation and Maintenance requirements for each BMP set forth in the Operations and Maintenance Plan approved by the issuing authority. h) All sediments or other contaminants removed from stormwater BMPs shall be disposed of in accordance with all applicable federal, state, and local laws and regulations. i) Illicit discharges to the stormwater management system as defined in 310 CMR 10.04 are prohibited. wpaformUoc• rev.2/27/08 Barnstable revised 4/11/2008 Page 6 of 10 {1 i LlMassachusetts Department of Environmental Protection Bureau of Resource Protection - Wetlands MassDEP File Number: WPA Form 5 - Order of Conditions SE3- 4854 Massachusetts Wetlands Protectibn':Act M.G.L. c. 131,,4§40 and § 237-1 to §*237-14 Town of Barnstable Code C. General Conditions Under Massachusetts Wetlands Protection Act (cont.) j) The stormwater management system approved in the Final Ord er'of Conditions"shall not be changed without the prior written approval of the issuing authority. Areas designated as qualifying pervious areas for purpose of the Cow Impact Site Design Credit'shall not'be with out hout the prior written approval`of the issuing authority. k) Access for maintenance of stormwater BMPs shall not be obstructed'or blocked:.Any fencing constructed around stormwater BMPs shall include access gates. Fence(s)shall be at least six inches above grade to allow for wildlife passage. at 'I, II ' n :,1 u,J,•is: I Special Conditions if you need more space for additional conditions, please attach a text document): A" A :J46 : .11 f:l 1!* . i D. Findings Under Municipal•,Wetlands Bylaw or Or'cina°nce 1. Is a municipal wetlands bylaw or ordinance applicable? ® Yes ❑ No 2. The Barnstable hereby finds (check one that applies): Conservation Commission a. ❑ that the,proposed work cannot be conditioned to meet,the standards set forth in a municipal ordinance or bylaw specifically: § 237-1 to§237-14 Town of Barnstable Code 1.Municipal Ordinance or Bylaw 2.Citation I. Therefore, work on this project may not go forward unless and until a revised Notice of Intent is submitted which provides measures which are adequate to;meet these standards, and a final Order of Conditions is issued. i b. ® that the following additional conditions are necessary t ;comply with a municipal ordinance or bylaw: , § 237-1 to § 237-14 Town of Barnstable Code 1 1.Municipal Ordinance or Bylaw d 2.Citation 3. The Commission orders that all work shall be performed in accordance with the following conditions and with the Notice of Intent referenced above. To the extent that the following conditions modify or differ from the plans, specifications, or other proposals submitted with the Notice of Intent, the conditions shall control. �r The special conditions relating to municipal ordinance or bylaw,,,',re as follows (if you need more space for additional conditions,attach a text document): See pp. 7.1, 7.2, and 7.3 {. wpaforrn5.doc- rev.2127/08 Barnstable revised 4/11/2008 Page 7 of 10 ;(Massachusetts Department of Environmental Protection 1 Bureau of Resource Protection - Wetlands MassDEP File Number: WPA Form 5 - Order of Conditions SE3- 4854 LLI Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 and § 237-1 to § 237-14 Town of Barnstable Code ,, E. Issuance i=, c Ln+y. ,- This Order is valid for three years, unless otherwise specified as a'special DEC T.4 200 condition pursuant to General Conditions#4, from the date of issuance. 1.Date of Issuance Please indicate the number of members who will sign this form: This Order must be signed by a majority of the Conservation Commission. `` 2.Numbe of signers The Order must be mailed by certified mail (return receipt requested)or hand delivered to the applicant. A copy also must be mailed or hand delivered at the same time to the appropriate Department of Environmental Protection Regional Office;if not filing electron ically!.and the-property.owner, if different from applicant. Signatures: IJ Notary Acknowledgeinent Barnstableit ; ?. Commonwealth of MassachusettsCouiity of pJ, On this ' Day of Month Year Before me, the undersigned Notary Public, personally appeared Name of Document Signer 11 ,( 3 proved to me through satisfactory evidence of identification, which was/were Description of evidence of identification to be the person whose name is signed on the preceding or attached document, and acknowledged to me that he/she signed it voluntarily for its stated purpose. As member of Barnstable Cityrrown Conservation Commission i 1 I Si fia - E'! CLAUDETTE 1500iZ.O4i`OER y Printe f ry rr ACHUSbM i�f , Vur:l; 'rtl;Yi f'+'ii�iluaoi Place notary seal and/or any stamp above My Co j�we' ate This Order is issued to the applicant as follows: ❑ by hand delivery on 19 by certified mail, return receipt requested,on i' DEC 14 2009 Date Name Signature Datei wpaform5.doc• rev.2/27108 Barnstable revised 4/11/2008 Page 8 of 10 141 t �l� i rt iC�i:' SE3-4854 :nit c t;l�li;ecl° Name: Peter Prygocki and Joann Johnson Approved Plan= December 2, 2009„Revised Site Plan by Robert P;E.,i,,l Special Conditions ofAppro"val I. Preface Caution: Failure to comply with all Conditions of this Order of Conditions can have seriousntln:t:: :�consequences. �.i 1.1: �1ll' J:1 t�IC. The consequence may include issuance of a stop work order,fines, requirement to removo :911f e un_pe.li(rmitfed structures,requirement to re-landscape to original condition,inability to obtain a certificate of compliance, and more. ;i d,,ri,... , iT :IUlV:.r! 2 ri'i`al. Sham I'V d.. The General Conditions of this Order begin on page 4 and continue on pages 5 through 7. The Special I1j Conditions are contained on pages 7.1,7.2 and 7.3 if necessary.All conditions require your compliance. II. Prior to the start of work,the following conditions shall be satisfied: ! ,:!' °a Co ' L ; 1. Within one month of receipt of this Order of Conditions and prior to the commencement of any work l f 'l I. L 'fE!i.lF :I I- 8'1 �.".,; •:ITi {'Sf ,' the"1 Vc ill. approved herein,General Condition number 8 (recording requirement)on page 4 shall be complied with. 2. It is the responsibility of the applicant,the owner and/or successor(s)and the project contractors to ensure that all conditions of this Order are complied with. The applicant shall provide copies of the Order of Conditions and approved plans(and any approved revisions thereof)to project contractors prior to the start of work. Barnstable Conservation Commission Forms A and B shall be completed and returned to the Commission prior to the start of work 3. General Condition 9 on page 4(sign requirement)shall be complied with. 4. The Conservation Commission shall receive written notice one(1)week in advance of the start of work. 5. The Natural Resources Department shall be notified at least twenty-one(21)working days prior to the start of work at the site,to inspect the areas for shellfish. If deemed necessary by the Shellfish Constable, shellfish shall be removed from the work area to a suitable site and/or replanted at the locus following construction. The foregoing measures for shellfish protection shall ensue`at the expense,of the applicant. i 6. A work protocol shall be submitted. Work shall not begin until the work protocol is approved by the Conservation Agent. li Page 7.1 ! Ai. The following additional conditions shall govern the project once work begins: 7. General conditions No. 12 and No. 13 (changes in plan)on page 5 shall.be complied with. 11101", Av"TJ 11 8. The Conservation Commission,its employees,and its agents shall have a right of entry' to inspect for compliance with the provisions of this Order of Conditions. 9.. Unless extended,this permit is valid for three years from the date of issuance' 'untli D E C 4 2012 10. Salt marsh shall not be disturbed. 11. CCA-treated piling and structural timber(greater than 3 inches thick)are allowed. Other-wise,no CCA- treated or creosote-treated materials shall be used. d � f 111.: i, 12. Grated deck surface providing 65%light penetration shall be used. 13. Work shall occur(luring the off-season only: October 15 through May 1. 14. The seasonal storage of floats shall be at a suitable upland site. Floats shall not be stored on banks, beaches,marshes or dunes. 15. Permanent piling shall'be driven into plaicie.'96ffie initial pilot hole jetting is allowed. The following special conditions in italics shall govern boat use at the approved pier. These 7 conditions shall continue over time. Note: For purposes of this Order of Conditions,the term"pier" shall refer not only to the linear pile-supported structure,but also to any of its components or wi is lf��c appendages such as the float(s),elf,tee,ramp,'outhaul piling,etc. al 16. Motorized craft shall not be used or berthed at the approved pier. 17. Berthed boats shall not ground at low tide. 18. A small sign shall be displayed at the end of the pier. It shall read SE34854; 242 Clamshell Cove Rd. Limitations: • No motorcrift allowed 19. Any desired pier lighting shall receive prior approval of the Conservation Co mmission. 20. Lead piling caps shall not be used. 21.' Work on the pier shall.ensue mid-tide rising to mid-tide falling or as otherwise necessary to provide a minimum 12"clearance for the work barge above the substrate. Page 7.2 22. rn this Order,a mooring permit for the applicant is neither implied nor anticipated. That is the domain of the Harbormaster. IV. After all work is completed, the following condition shall be promptly met: 23. At the completion of work,or by the expiration of this Order,the applicant shall request in writing a Certificate of Compliance for the work herein permitted. Barnstable Conservation Commission Form C shall be completed and returned with the request for a Certificate of Compliance Where a project has been completed in accordance with plans stamped by a registered professional engineer,architect, landscape I architect or land surveyor,a written statement by such a professional person certifying substantial compliance with the plans and setting forth what deviation,if any,exists with the record plans approved in the Order shall accompany the request for a Certificate of Compliance. 1 { a i A. 1, !I I i 7.3 ail i' i i I r: i' il.. 1 I „I Page 7.3 i [ � ~ | k1 ` �ei ��h� ��' ' � � « ��u�/m��K�0�� 00�� ' ' � — ''~' ` ` _ ,,. ^_^ x-o.��«»� ��b[8@U of Resource ��[Ot8c�0 .��/81@Dd8 x�Ua -|'. x�g�� ' Number: �� '' �� ^�.�` � m� u �~e n �� _~ ��x u��:��"�� ^�~ a�oo��| ' ' '�-'` -- -' '~~^~^~~^~ --- '~~' ��8SS8ChUSet�/ l�et@ndS �»rOteC�On - M.G'L' c. 13 +°^", � d .. o .- ode � F. �� " . " �°pm,«uo~p || The applicant, the ,owner, anypereo, n, agghevodbv thisOrder, any owner of land abutting -the �"` |"a"'"n"d" n ub~ ie c ttothim [rder, oranyb*nreaidantmofthecib/cv townin which such land kslocated, are hereby notified of their right to request the appropriate MassDEP Regional Office to issue a Superseding Order of Conditions. The request must be made by certified mail or hand delivery to the Department, with the appropriate filing .andaoonp|etedRequ � "' "epodnent—| - Fee Jnan�D � | "m nu provided /�� fu�l�~ �h''\in310CWR 1U.O3/7>��thinten business dayo'�on the date of�suanoeof this 3r�e^r~copy of the request shall at the same time be sent by certified mail or hand delivery bn the Conservation"Commission and bo the applicant, if he/she im not the appellant. Any appellants seeking to appeal the Department's Superseding Order associated with this appeal will be required bn demonstrate prior participation in the/e*iowofthiopnojeoLPnaviouopartioipotioninthopornitpooueedinQneonotheaubnioaion ~ w'""" i ^"' xuUon0otheConaenxaUonConmkxuionphorbnthec|oaeofthopub|ioheohng requesting a ""p"s"" /yu/derorDetonninoUon. o[providingvhttoninfnnnaUonbotheOaportnontph"rhoisauoncemaSuperoeomgOndororDebanninoUun. The request shall state clearly and concisely the objections to the Order which is being appealed and how the Order does not contribute ho the protection of the ~ interests idenUfi. din the �Wassoohusa�uVVet!anda ProtecUonAct(��.G.L. c. 131. §40\. and ia inconsistent vviththe weU--doregulations (310CK8R10OU) TotheextentthatthoOnderisboo'dononnunioipa| ondinanoonrby~^ andnot ont ' ��aamanhu-- '' appellate jurisdiction. u��us SaotkomG, Recording Information im available on the following page. yn� ` . } � � . . i ' U � i 'i oo"m"m° revised*nx20v , Page omw � �[ Massachusetts;Department.of E�nyi,ronmental Protection BLireau of Resource Protection - Wetlands MassDEP File Number: WPA Form 5 — Order-of Conditions "4uml,,-i - SE3- 4854 Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 and § 237-1 to § 237-14 Town of Barnstable Code G. Record ing'Informatiob) .eds ,+ This Order of Conditions must be recorded in the Registry of Deeds or the Land Court for the district in which the land is located,within the chain of title of the affected property. In the case'ofrecorded land, the Final Order shall also be noted in the Registry's Grantor Index under the name of the owner of the land subject to the Order. In the case of registered land, this Order shall also be noted on the Land Court Certificate of Title of the owner of the land subject to the Order of Conditions. The recording information on this page shall be submitted to the Conservation Commission listed below. Barnstable_. i 112 ,f 1f,,_:, ff« Conservation Commission Detach on dotted line, have stamped by the Registry of Deeds and submit to the Conservation Commission. -------------------------------------------------- ------------------------------------------------------------------------ To: ' r, rt 'r ''!ic.1s is o it t Barnstable _... Conservation Commission Please be advised that the Order of Conditions for the Project at: '•`I:'I .y r; tit J-. i;:: ` +:►: 242 Clarrmshell Cove•Rd., Cotuit, MA1,026351, t SE3 4854 Project Location MassDEP File Number - �. �1 r 4. Has been recorded atithe Registry of Deeds of: y: Barnstable County Book Page for: Property Owner - - and has been noted in the chain of title,of,the affected property in: Book Page In accordance with the Order of Conditions issued on: Date If recorded land,the instrument number identifying this transaction is: Bk . 24.24 0 E`er 1 14 -g71o6r0$g Instrument Number If registered land, the document number identifying this transaction is: Document Number Signature of Applicant wpaform5.doc- rev.2/27/08 Barnstable revised 4/11/2008 1 Page 10 of 10 i 1t 1 I CERTIFY THAT THIS PLAN HP PREPARED IN CONFORMITY WIT RULES AND REGULATIONS OF REGISTERS OF DEEDS OF THE COMMONWEALTH OF MASSACHI Professional Land Surveyor COTUIT ` Z g CLAMSHELL COVE ROAD L=9.2 9' 115.76' PARCEL ID: A.M. 005-005 PETER M. PRYGOCKI & JOANN JOHNSON 242 CLAMSHELL COVE RD. 11', COTUIT, MA. 0263500 . - - LC a Q O� EX�S OE K m 44 a � OONG - U W 00 PARCEL a A.M. 005- 0 P ROBERT W SLQp SUSAN J. 8C TOP OF 41 SPARHAW LANDSCAPE MARSHFIELD, h i0f W 3 WIDE PATH TIMBERS � m2 t • �j sw m OM OF N SPARTINA PATENS & MIXED GRASES MHW=2,5 SPARTINA ALTERNIF LORA `-- � ® AR H 0. x 8' GRATED PLATFORM EL. 5.3 OF MAS CD v%�Qy `�q+c �' � RT A• yG dO KE lJ CIVIL 0642 SHOESTT►'//VG 6.4CO Y 20 CIt'AI C. I° • 1 Massachusetts Department of Environmental Protection Bureau of Resource Protection -Waterways Regulation Program X232409 Chapter 91 Waterways License Application -310 CnnR 9.00 Transmittal No. Water-Dependent,Nonwater-Dependent,Amendment G. Municipal Zoning Certificate Peter Prygocki Name of Applicant 242 Clamshell Cove Road Shoestring Bay Cotuit Project street address Waterway Cityrrown Description of use or change in use: to construct and maintain a private recreational dock with outhaul pile appurtenant to an existing stele family dwelling. To be completed by municipal clerk or appropriate municipal official: °I hereby certify that the project described above and more fully detailed in the applicant's waterways license application and plans is not in violation of local zoning ordinances and bylaws." Printed Name of Municipal Official Date ture f unicipal Officia Tit a tl City/Town CH91 App.doc-Rev.6/06 Page 6 of 13 Enter your transmittal number X232409 Transmittal Number . Your unique Transmittal Number can be accessed online: http://mass.gov/dep/service/online/trasmfrm.shtmi or call ILI MassDEP's InfoLine at 617-338-2255 or 800-462-0444(from 508,781,and 978 area codes). Massachusetts Department of Environmental Protection Transmittal Form for Permit Application and Payment 1. Please type or .A..Pe.rmit_Information___ print.A separate - Transmittal Form BRP WW01a Water Dependent-General(A-H) must be completed 1.Permit Code:7 or 8 character code from permit instructions 2.Name of Permit Category for each permit q application. 3.Type of Project or Activity 2. Make your check payable to B. Applicant Information --Firm or-Individual the Commonwealth pp of Massachusetts and mail it with a 1.Name of Firm-Or,if party needing this approval is an individual enter name below: copy of this form to: DEP,P.O.Box Prygocki Peter 4062,Boston,MA 2.Last Name of Individual 3.First Name of Individual 4.MI 02211. 242 Clamshell Cove Road 5.Street Address 3. Three copies of Cotuit MA 02635 this form will be 6.Cityrrown 7.State 8.Zip Code 9.Telephone# 10.Ext.# needed. Copy 1 -the 11.Contact Person 12.e-mail address(optional) original must accompany your permit application. C. Facility, Site or Individual Requiring Approval Copy 2 must accompany your Prygocki Pier fee payment. 1.Name of Facility,Site Or Individual Copy 3 should be 242 Clamshell Cove Road retained for your 2.Street Address records Cotuit MA 02635 4. Both fee-paying 3.City/Town 4.State 5.Zip Code 6.Telephone# 7.Ext.# and exempt applicants must 8.DEP Facility Number(if Known) 9. Federal I.D.Number(if Known) 10.BWSC Tracking#(if Known) mail a copy of this _ transmittal for,to: D. Application Prepared by (if different from Section B)* MassDEP A. M. Wilson Associates, Inc. P.O.Box 4062 Boston,MA 1.Name of Firm Or Individual 02211 20 Rascally Rabbit Road, Unit 3 2.Address •Note: Marstons Mills MA 02648 508-420-9792 For BWSC Permits, 3.Cityrrown 4.State 5.Zip Code 6.Telephone# 7.Ext.# enter the LSP. Arlene M. Wilson, PWS 8.Contact Person 9.LSP Number(BWSC Permits only) E. Permit - Project Coordination 1. Is this project subject to MEPA review? ❑yes ® no If yes, enter the project's EOEA file number-assigned when an Environmental Notification Form is submitted to the MEPA unit: EOEA File Number F. Amount Due DEP Use Only Special Provisions: 1. ❑Fee Exempt(city,town or municipal housing authority)(state agency if fee is$100 or less). Permit No: There are no fee exemptions for BWSC permits,regardless of applicant status. ) 2. ❑Hardship Request-payment extensions according to 310 CMR 4.04(3)(c). Rec d Date: 3. ❑Alternative Schedule Project(according to 310 CMR 4.05 and 4.10). 4. ❑Homeowner(according to 310 CMR 4.02). Reviewer. $175.00 Check Number Dollar Amount Date Massachusetts Department of Environmental Protection t - Bureau of Resource Protection -Waterways Regulation Program X232409 Chapter 91 Waterways License Application -310 CMR 9.00 Transmittal No. Water-Dependent, Nonwater-Dependent,Amendment Important:When filling out forms A. Application Information (Check one) on the computer, use-only the-tab. NOTE:-For-Chapter-91-Simplified-License-application-for.m-and-information-see-the Self-Licensing key to move your Package for BRP WW06. cursor-do not use the returnum- Name-(Complete:Application=Sections)��:Check-One�� -- ..�._:- Fee,:-r. . Application#--'--- key_ VQ WATER-DEPENDENT- General (A-H) ® Residential with <4 units $175.00 BRP WW01a ❑ Other $270.00 BRP WW01 b For assistance ❑ Extended Term $2730.00 BRP WW01c incompleting this .................................................................-••--•............-••---......--......-.._.._..............---•--.._........-••-•---•-••--. application,please Amendment(A-H) ❑ Residential with <4 units $85.00 BRP WW03a see the — "Instructions". ❑ Other $105.00 BRP WW03b NONWATER-DEPENDENT- Full (A-H) ❑Residential with <4 units $545.00 BRP WW15a ❑ Other $1635.00 BRP WW15b ❑ Extended Term $2730.00 BRP WW15c Partial(A-H) ❑ Residential with <4 units $545:00 BRP WW14a ❑ Other $1635.00 BRP WW14b ❑ Extended Term $2730.00 BRP WW14c Municipal Harbor Plan (A-H) ❑ Residential with <4 units $545.00 BRP WW16a ❑ Other $1635.00 BRP WW16b ❑ Extended Term $2730.00 BRP WW16c Joint MEPA/EIR(A-H) ❑ Residential with <4 units $545.00 BRP WW17a ❑ Other $1635.00 BRP WW17b ❑ Extended Term $2730.00 BRP WW17c Amendment(A-H) ❑ Residential with <4 units $435.00 BRP WW03c ❑ Other $815.00 BRP WW03d ❑ Extended Term $1090.00 BRP WW03e CH91App.doc-Rev.6/06 Page 1 of 13 Massachusetts Department of Environmental Protection �I Bureau of Resource Protection -Waterways Regulation Program X232409 Chapter 91 Waterways License Application -310 CMR 9.00 Transmittal No. Water-Dependent,Nonwater-Dependent,Amendment B. Applicant Information Proposed Project/Use Information 1. Applicant: Peter Prygocki ` : .... ,.z.�..�tJame•: . ;.;.,max:-..�,...�-,��,:_.--��:�:,.� ..E-mail Address d. _ c/o A. M. Wilson Associates, Inc. 20 Rascally Rabbit Road, Unit 3 Note:Please refer Mailing Address to the"Instructions" Marstons Mills MA 02648 Cityrrown State Zip Code 508-420-9792 508-420-9795 Telephone Number Fax Number 2. Authorized Agent(if any): Arlene M. Wilson, PWS amwilsonassoc@amwilsonassociates.com Name E-mail Address A. M. Wilson Associates, Inc. 20 Rascally Rabbit Road, Unit 3 Mailing Address Marstons Mills MA 02648 CityrFown State Zip Code 508-420-9792 508-420-9795 Telephone Number Fax Number C. Proposed Project/Use Information 1. Property Information (all information must be provided): Peter Prygocki and Joann Johnson Owner Name(if different from applicant) 5/5 fax Assessor's Map and Parcel Numbers Latitude Longitude 242 Clamshell Cove Road, Cotuit MA 02635 Street Address and Cityrrown State Zip Code 2. Registered Land ❑Yes ❑ No 3. Name of the water body where the project site is located: Shoestring Bay 4. Description of the water body in which the project site is located (check all that apply): Type Nature Designation ❑ Nontidal river/stream ® Natural ❑Area of Critical Environmental Concern ® Flowed tidelands ❑ Enlarged/dammed ❑ Designated Port Area ❑ Filled tidelands ❑ Uncertain ❑ Ocean Sanctuary ❑ Great Pond ❑ Uncertain ❑ Uncertain CH91App.doc•Rev.6/06 Page 2 of 13 i Massachusetts Department of Environmental Protection 4 - Bureau of Resource Protection -Waterways Regulation Program X232409 Chapter 91 Waterways License Application -310 CMR 9.00 Transmittal No. Water-Dependent,Nonwater-Dependent,Amendment C. Proposed Project/Use Information (cont.) Select use(s)from Project Type Table 5. Proposed Use/Activity description on pg.2 of the "Instructions" Construction and maintenance of private recreational pier with outhaul pile for marine navigational access. 6. What is the estimated total cost of proposed work(including materials&labor)? $75,000.00 7. List the name&complete mailing address of each abutter(attach additional sheets, if necessary). An abutter is defined as the owner of land that shares a common boundary with the project site, as well as the owner of land that lies within 50' across a waterbody from the project. Robert& Susan Bothwell 41 Sparhawk Path, Marshfield, MA 02050 Name Address Stephen & Susan Regan, Trs 9 Kingswood Road, Auburndale, MA 02466 Name Address Name Address D. Project Plans 1. I have attached plans for my project in accordance with the instructions contained in (check one): ® Appendix A(License plan) ❑ Appendix B (Permit plan) 2. Other State and Local Approvals/Certifications ❑401 Water Quality Certificate Date of Issuance ®Wetlands SE34854 File Number ❑ Jurisdictional Determination JD- File Number ❑ MEPA File Number ❑ EOEA Secretary Certificate Date ❑ 21 E Waste Site Cleanup RTN Number CH91App.doc-Rev.6/06 Page 3 of 13 Massachusetts Department of Environmental Protection Bureau of Resource Protection -Waterways Regulation Program X232409 `t Chapter 91 Waterways License Application -310 CMR 9.00 Transmittal No. Water-Dependent, Nonwater-Dependent,Amendment E. Certification All applicants, property owners and authorized agents must;sign All future application correspondence may be signed by the authorized agent alone. _. ._ -__Lhereby�make=application_fora_permit:or license;�to-authorize�the=activities=l-have-deseribed=herein=Upon -- my signature, I agree to allow the duly authorized representatives of the Massachusetts Department of Environmental Protection and the Massachusetts Coastal Zone Management Program to enter upon the premises of the project site at reasonable times for the purpose of inspection." "I hereby certify that the information submitted in this application is true and accurate to the best of my knowledge." Applicant's signature Date (See Attached) Property Owner's signature(if different than applicant) Date A.M.Wilson Associates,Inc. Agent's signature(if applicable) Arlene M.Wilson Date CH91App.doc•Rev.6/06 Page 4 of 13 a A.M.Wilson Associates Inc. June 30, 2009 Peter Prygocki 242 Clamshell Cove Road Cotuit, MA 02635 Re: Design and Permitting Assistance 242 Clamshell Cove Road, Cotuit (Our File No. 1.1603.00) Dear Mr. Prygocki: In accordance with our recent discussions, A. M. Wilson Associates, Inc. is pleased to provide the following revised Scope of Services for design and permitting of a private residential pier at 242 Clamshell Cove Road, Cotuit. As we discussed, nothing in the permitting situation has changed. The Conservation Commission in Barnstable still hates piers. They have adopted a shellfish habitat map which shows a rather high value for this site. There is in general little scientific support for the mapping., We recommend, and have included in this proposal, a shellfish inventory for the site to use as backup for-our application. Pier permitting includes not only the local Conservation Commission but also permits from the Mass Division of Waterways, the U S Army Corps of Engineers and a building permit. You should expect the process to take two years from authorization. The utility of the pier will be primarily based on the depth of water available at Mean Low Tide. Thus, we suggest getting the bathymetric survey completed and then making decisions about how or whether to proceed as we will then be able to predict whether you can get a motor boat at the site. Tasks we believe required for your project are listed below. 1.0 Survey - 1.1 ]Research - Research will be performed at the Barnstable Registry of Deeds and Barnstable Town Hall to obtain, as available, copies of relevant plans and deeds of the site, abutting roadways, and any permits for existing development. Agency mapping for wetlands restrictions, Endangered Species habitat; flooding and similar issues will be obtained and viewed. 20 Rascally Rabbit Road 1 Unit 3 508 420-9792 Marstons Mills, MA 02648 FAX 508 420-9795' 1.2 Wetlands Delineation - A wetlands specialist will visit the site to identify the limits. of vegetated wetlands based on requirements of MGL Ch. 131 sec. 40 and the Town of Barnstable Wetlands Ordinance. 1.3 Field—A field crew will visit the site to: establish horizontal control; establish vertical control tied to Mean Low Water Datum; locate significant man-made features on and abutting the site including boundary monuments, buildings, fences, moorings, abutting piers and channel markers; locate significant natural features including previously identified wetland resource areas, Mean High and Mean Low Water, bathymetric information from Mean Sea Level to Channel or 200'beyond MLW whichever is closer to shore and from 100'beyond each side line. 1.4 Base Map—Sufficient office work including calculation, plotting and drafting will be performed to generate an existing conditions work sheet and ink-on-mylar topographic base map suitable for later plotting design and permitting. 2.0 Environmental Studies 2.1 Shellfish Report-The bottom in the area of the proposed pier and at least 50' beyond the pier in all directions will be sampled for: bottom type;prevalence of marine grasses; and shellfish by species and size. Sample plot layout will conform to Conservation Commission requirements that at least 0.5% of the site's shorefront be sampled within the project area. A report will be prepared for use in later permitting. 3.0 Pier Design - Utilizing the base sheet, shellfish inventory and Town pier requirements, a pier plan showing the site layout, sections and profiles will be prepared for use in later permitting. The pier will be sited so as to take advantage of the deepest water, closest to shore. It cannot extend more than 62.5' beyond MLW. 4.0 Permitting 4.1 Wetlands - In accordance with the requirements of MGL Ch. 131, Sec. 40 and the Barnstable Town Ordinances, and utilizing plans and support materials outlined above, a Notice of Intent will be prepared and filed with the Barnstable Conservation Commission. Appropriate project personnel will attend the public hearing on the project and offer testimony on your behalf. It is assumed that attendance at 2 hearing sessions will be required for the project. Staff will also attend the meetings of the Town Waterways Committee and the Town Shellfish Committee at which the projects will be discussed. Up to 6 hours of staff time is included for meetings under this task. I 2 4.2 Chapter 91 Licensing-Plans will be reformattedao meet requirements of the Waterways Division. Utilizing these reformatted plans---application-forms-including - Municipal Clerk's Certification and Planning Board Certification will be completed. A CZM Consistency Certification and Mass. Historic Commission Project Notification Form will also be prepared. This documentation, together with project plans, will be filed with appropriate agencies as required. Up to 4 hours of time are included for negotiations with agency personnel. Legal advertising and agency/abutter notifications will be placed when required. 4.3 USACE - Utilizing Plans as formatted for the Ch 91 License, a Category I confirmation or Category II permit application will be filed with the Corps. Up to 4 hours are included for negotiations with agency personnel. 5.0 Additional Services A. M. Wilson Associates, Inc. will provide any of the following services upon request. Fees for additional services will be charged on a per diem basis in accordance with our current fee schedule. i Existing conditions/topographic/property line survey. • Percolation testing and septic system design. • Fisheries inventories and assessments. Habitat evaluation for Endangered Species if required by MESA. Meeting and negotiation time in addition to that specifically noted above. • Environmental design services related to landscape, non-structural drainage design or other mitigative measures. 0 Assistance with other environmental studies and permitting procedures including MEPPA, archaeological or historic inventories, ZBA assistance. 0 Plan changes required by any reviewing board or agency or by the client. • Appeal assistance. 3 =�_ onstruction'services. r a �__..-Other-services not-specifically-noted above. -- :......_:._:._ ... .: _.____. . ...:.._:_._. ...... ..__.__.. Fees and Billing Fees for our services will be billed on a time charge plus expenses basis. Reimbursable expenses will be charged at cost. Terms for payment are net ten (10) days from receipt of invoice. Any balance outstanding for more than 30 days will be charged interest at 1.5%per month, or 18%per annum. Invoices outstanding for more than 45 days may be deemed cause to suspend work on the project. Billings for services will be at the close of the month for work-in-progress, and the balance upon completion of the above services. It is understood that this is a professional engagement on a fee-for-services basis consisting of the personal services of the staff of A. M. Wilson Associates, Inc. The fees for these services are those customarily charged by A. M. Wilson Associates, Inc. and are not in any way contingent upon the findings of any Board or Agency, nor of our own findings as to the developability of the subject site. It is further understood that because of the nature of this engagement and the uncertainty of the time required by others, that this work and the fees therefore are essentially open-ended. However, we believe it is important for all business agreements to have some mutual understanding of the costs, and thus we provide the following estimate for labor costs associated with services outlined above: ESTIMATE—LABOR Task 1.0—Survey . . . . . . . . . . $ _ Tasks 2.0—4.0 . . . . . . . . . . . . .$ Although we do not normally include expenses in our estimates due to the frequency with which they have a tendency to change, for planning purposes you should budget$ �r filing fees, recording, mileage and deliveries. This estimate is good for 60 days. 4 "Anthor�zafion We are able to schedule,work witlined above-upon.:receipt-of-a..signed copy_of this_proposal,_._-.._.. and a retainer in the ammint of? .• 0. The retainer will be applied to the final invoice for the project. We look forward to being of assistance to you with this project. If you have any questions, please do not hesitate to call our office. Yours, A. M. WILSON ASSOCIATES, INC. Arlene M. Wilson, PWS Principal Environmental Planner AUTHORIZED AND APPROVED (Our File No. 2.1603.00) a ,� krr� iMY6o�K t (Client signature (Client name-please print) Zq-Z CCjfA45-&ClL COVE $Zb C07VJ T KA (Title) (Billing address) �uo35 ��( o j pe76er.M o �e_k Q✓ems,err ksr n�P_ss_ (Date) (Client emai ) Coo'l 2-Go- 09o7 Cc-c-r0 (Bank Reference) (Client telephone) '�-oo-6 2-?-- 7o-7 o so,S-_ Gal - S'74 (Telephone) (Client fax number) i 5 Massachusetts Department of Environmental Protection Bureau of Resource Protection -Waterways Regulation Program X232409 Chapter 91 Waterways License Application -310 CMR 9.00 Transmittal No. Water-Dependent, Nonwater-Dependent,Amendment F. W 7rways Dredging Addendum 1. Provide a cription of the dredging project ❑ Maintenance edging(includeaast dredge date 4,permit no) ❑/�nement Dredging_ Purpose of Dredging 2. What is the volume(cubic y s)of material to be dredged? 3. What method will be used to dredge? ❑ Hydraulic ❑ Mechani ❑ Other 4. Describe disposal method and provid sposal to i n (include separate disposal site location map) Xapplicand f gra* size analysis. If grain size is compatible for bea ourishment purposes, the co ends that the dredged material be used as beach n shment for public n the event beach nourishment is proposed for private pro y, pursuant to 310 )1, public access easements below the existing high water ma hall be secured by submitted to the Department. i I CH91App.doc-Rev.6/06 Page 5 of 13 Massachusetts Department of Environmental Protection Bureau of Resource Protection -Waterways Regulation Program X232409 Transmittal No. Chapter 91 Waterways License Application -310 CMR 9.00 Water-Dependent, Nonwater-Dependent,Amendment G. Municipal Zoning Certificate Peter Prygocki Name of Applicant 242 Clamshell Cove Road Shoestring Bay Cotuit -._-..-Project-street-address_ - Waterway,-=,.__ _... _. _ __Gity/rown- Description of use or change in use: to construct and maintain a private recreational dock with outhaul pile appurtenant to an existing single family dwelling. I 1' Tobecompleted by municipal clerk or appropriate municipal official: °I hereby certify that the project described above and more fully detailed in the applicant's waterways license application and plans is not in violation of local zoning ordinances and bylaws." Printed Name of Municipal Official Date Signature of Municipal Official Title City/Town CH91App.doc-Rev.6/06 Page 6 of 13 Massachusetts Department of Environmental Protection Bureau of Resource Protection -Waterways Regulation Program X232409 Chapter 91 Waterways License Application -310 CnnR 9.00 Transmittal No. Water-Dependent, Nonwater-Dependent,Amendment H. Municipal Planning Board Notification Notice to Peter Prygocki Applicant: Name of Applicant Section H should 242 Clamshell Cove Road Shoestring Bay Cotuit be completed and_ Pro'ect-stceetaddress :=. Waterway submitted along with the original Description of use or change in use: application material. to construct and maintain a private recreational dock with outhaul pile appurtenant to an existing single family dwelling. To be completed by municipal clerk or appropriate municipal official: "I hereby certify that the project described above and more fully detailed in the applicant's waterways license application and plans have been submitted by the applicant to the municipal planning board." Printed Name of Municipal Official Date Signature of Municipal Official Title Cityrrown Note:Any comments, including but not limited to written comments, by the general public, applicant, municipality, and/or an interested party submitted after the close of the public comment period pertaining to this Application shall not be considered, and shall not constitute a basis for standing in any further appeal pursuant to 310 CMR 9.13(4)and/or 310 CMR 9.17. CH91App.doc•Rev.6/06 Page 7 of 13 Massachusetts Department of Environmental Protection • Bureau of Resource Protection -Waterways Regulation Program X232409 Chapter 91 Waterways License Application -310 CMR 9.00 Transmittal No. Water-Dependent, Nonwater-Dependent,Amendment Appendix A: License Plan Checklist General View ❑ PE or RLS, as deemed appropriate by the Department, stamped and signed, in ink, each sheet -- -within-8=A/2 inch-by=1-l--inch-border-=-=- --- _ sv< ❑ Format and dimensions conform to"Sample Plan" (attached) ❑ Minimum letter size is 1/8 of an inch if freehand lettering, 1/10 of an inch if letter guides are used ❑ Sheet number with total number in set on each sheet ❑ Title sheet contains the following in lower left: Plans accompanying Petition of[Applicant's name, structures and/or fill or change in use, waterway and municipality] ❑ North arrow ❑ Scale is suitable to clearly show proposed structures and enough of shoreline, existing structures and roadways to define its exact location ❑ Scale is stated & shown by graphic bar scale on each sheet ❑ Initial plans may be printed on bond; final plans due before License issuance must be on 3mil Mylar. Structures and Fill ❑ All Structures and Fill shown in full BLACK lines, clearly labeling which portions are existing, which are Proposed and indicating Existing Waterways Licenses ❑ Cross Section Views show MHW*and MLW*and structure finish elevations ❑ Dredge or Fill, actual cubic yardage must be stated and typical cross sections shown ❑ All Structures and Fill shown in full BLACK lines, clearly labeling which portions are existing, which are Proposed and indicating Existing Waterways Licenses ❑ Cross,Section Views show MHW*and MLW*and structure finish elevations ❑ Dredge or Fill, actual cubic yardage must be stated and typical cross sections shown ❑ Actual dimensions of structures(s)and or fill and the distance which they extend beyond MHW*or OHW* ❑ Change in Use of any structures on site must be stated *See 310 CMR 9.02, Waterways Regulations definitions of High Water Mark, Historic High Water Mark, Historic Low Water Mark, and Low Water Mark. Note: DEP may, at its discretion, accept appropriately scaled preliminary plans in lieu of the plans described above. In general, DEP will accept preliminary plans only for non-water dependent projects and projects covered by MEPA to address site design components such as visual access, landscaping & site coverage. Anyone wishing to submit preliminary plans must obtain prior approval of the DEP Waterways Program before submitting them with their application. I CHMpp.doc•Rev.6/06 Page 8 of 13 Massachusetts Department of Environmental Protection • Bureau of Resource Protection -Waterways Regulation Program X232409 Chapter 91 Waterways License Application -310 CMR 9.00 Transmittal No. Water-Dependent, Nonwater-Dependent,Amendment Appendix A: License Plan Checklist (cont.) Boundaries ❑ Property lines, full black lines, , along with abutters' names and addresses ❑ Mean High Water(MHW)*or Ordinary High Water(OHW)*, full black line ❑ Mean Low Water(MLW)*, black dotted line, (.............) ❑ Historic MHW*or OHW* ❑ Historic MLW*(... ... _.._) ❑ State Harbor Lines, black dot-dash line (— .—. —. -)with indication of Chapter&Act establishing them (Ch. , Acts of) ❑ Reference datum is National Geodetic Vertical Datum(NGVD)or(NAVD). ❑ Floodplain Boundaries according to most recent FEMA maps ❑ Proposed & Existing Easements described in metes& bounds Water-Dependent Structures ❑ Distance from adjacent piers, ramps or floats(minimum distance of 25'from property line, where feasible) ❑ Distance from nearest opposite shoreline ❑ Distance from outside edge of any Navigable Channel ❑ Access stairs at MHW for lateral public passage, or 5 feet of clearance under structure at MHW. Non Water-Dependent Structures ❑ Depict extent of"Water-dependent Use Zone". See Waterways Regulations at 310 CMR 9.51-9.53 for additional standards for non water-dependent use projects. Note: Final Mylar project site plans will be required upon notice from the Department, prior to issuance of the Chapter 91 Waterways License. CH91App.doc-Rev.6/06 Page 9 of 13 Massachusetts Department of Environmental Protection • Bureau of Resource Protection -Waterways Regulation Program X232409 Chapter 91 Waterways License Application -310 CnnR 9.00 Transmittal No. Water-Dependent, Nonwater-Dependent,Amendment Appendix A: License Plan Checklist Cont. ':+ivyr.�-_r..__..4n:-4!=T+..nM.--1.'__ {:1.nn-+.•T+rtc:c+.mwr._.—._.___... '.�.-aa—siT--.z:�r—+aa-.+si :.tc--s_i+-.._... w Registry Statement 3112 inche 5 inche Locus Map 3 Fiist Sheet 0 my aD zm 3J$„ a 1 „ 21/4 inche U Sample Plan U 8112 inches P.E. or RIS stamp �' --3 3/4 inch e Plan Accompany ing Petition of... DEP Stamp First Sheet Only 3/4 "Border CHMpp.doc•Rev.6/06 Page 10 of 13 Massachusetts Department of Environmental Protection Bureau of Resource Protection -Waterways Regulation Program X232409 Transmittal No. Chapter 91 Waterways License Application -310 CMR 9.00 Water-Dependent, Nonwater-Dependent,Amendment Appendix B: Dredging Permit Plan Checklist For projects applying for dredging permits only, enclose drawings with the General Waterways Application that include the following information: ❑ Submit one original of all drawings. Submit the fewest number of sheets necessary to adequately illustrate the project on 8-1/2 inch X 11 inch paper. ❑ A 1-inch margin should be left at the top edge of each drawing for purposes of reproduction and binding. A 1/2 inch margin is required in the three other edges. ❑ A complete title block on each drawing submitted should identify the project and contain: the name of the waterway; name of the applicant; number of the sheet and total number of sheets in the set; and the date the drawing was prepared. ❑ Use only dot shading, hatching, and dashed or dotted line to show or indicate particular features of the site on the drawings. ❑ If deemed appropriate by the Department, certification by the Registered Professional Engineer or Land Surveyor is included. Plan View ❑ North Arrow ❑ Locus Map ❑ Standard engineering scale. ❑ Distances from channel lines and structures if appropriate. ❑ Mean high water and mean low water shorelines (see definitions of"High Water Mark"and"Low Water Mark"at 310 CMR 9.02, C. 91 Regulations). ❑ Dimensions of area proposed to be dredged or excavated. ❑ Notation or indication of disposal site. ❑ Volume of proposed dredging or excavation. ❑ Ordinary high water, proposed drawdown level, and natural (historic) high water(for projects lowering waters of Great Ponds). Section Views ❑ Existing bottom and bank profiles. ❑ Vertical and/or horizontal scales. ❑ Proposed and existing depths relative to an indicated datum. ❑ Elevation and details of control structure(for projects lowering waters of Great Ponds). CHMpp.doc-Rev.6/06 Page 11 of 13 Massachusetts Department of Environmental Protection Bureau of Resource Protection -Waterways Regulation Program X232409 Chapter 91 Waterways License Application -310 CMR 9.00 Transmittal No. Water-Dependent, Nonwater-Dependent,Amendment Appendix C: Application Completeness Checklist Please answer all questions in the General Waterways Application form. If a question does not apply to your project write"not applicable"(n/a) in that block. Please print or type all information provided on the form. Use black ink(blue ink or pencil are not easily reproducible, therefore, neither will be accepted):.If additional space is-needed, attach-extra 8-112"x 11"sheets-of paper. - ❑ Proper Public Purpose: For nonwater-dependent projects, a statement must be included that explains how the project serves a proper public purpose that provides greater benefit than detriment to public rights in tidelands or great ponds and the manner in which the project meets the applicable standards. If the project is a nonwater-dependent project located in the coastal zone, the statement should explain how the project complies with the standard governing consistency of the policies of the Massachusetts Coastal Zone Management Program, according to 310 CMR 9.54. If the project is located in an area covered by a Municipal Harbor Plan,the statement should describe how the project conforms to any applicable provisions of such plan pursuant to 310 CMR 9.34(2). ❑ Plans: Prepared in accordance with the applicable instructions contained in Appendix A-13 of this application. For initial filing, meet the requirements of 310 CMR 9.11(2)(b)(3). ❑ Applicant Certification:All applications must be signed by"the landowner if other than the applicant. In lieu of the landowner's signature, the applicant may provide other evidence of legal authority to submit an application for the project site."If the project is entirely on land owned by the Commonwealth(e.g. most areas below the current low water mark in tidelands and below the historic high water mark of Great Ponds), you may simply state this in lieu of the"landowner's signature". ❑ Municipal Zoning Certification: If required, applicants must submit a completed and signed Section E of this application by the municipal clerk or appropriate municipal official or, for the initial filing, an explanation of why the form is not included with the initial application. If the project is a public service project subject to zoning but will not require any municipal approvals, submit a certification to that effect pursuant to 310 CMR 9.34(1). ❑ Municipal Planning Board Notification:Applicants must submit a copy of this application to the municipal planning board for the municipality where the project is located. Submittal of the complete application to DEP must include Section H signed by the municipal clerk, or appropriate municipal official for the town where the work is to be performed, except in the case of a proposed bridge, dam, or similar structure across a river, cove, or inlet, in which case it must be certified by every municipality into which the tidewater of said river, cove, or inlet extends. ❑ Final Order of Conditions:A copy of one of the following three documents is required with the filing of a General Waterways Application: (1)the Final Order of Conditions(with accompanying plan) under the Wetlands Protection Act; (2)a final Determination of Applicability under that Act stating that an Order of Conditions is not required for the project; or(3)the Notice of Intent for the initial filing (if the project does not trigger review under MEPA. ❑ Massachusetts Environmental Protection Act(MEPA): MGL 30, subsections 61-61A and 301 CMR 11.00, submit as appropriate: a copy of the Environmental Notification Form (ENF)and a Certificate of the Secretary of Environmental Affairs thereon, or a copy of the final Environmental Impact Report(EIR)and Certificate of the Secretary stating that it adequately and properly complies with MEPA; and any subsequent Notice of Project change and any determination issued thereon in accordance with MEPA. For the initial filing, only a copy of the ENF and the Certificate of the Secretary thereon must be submitted. Note: If the project is subject to MEPA,the Chapter 91 Public Notice must also be submitted to MEPA for publication in the"Environmental Monitor". MEPA filing deadlines are the 15'"and 30"'of each month. CH91App.doc-Rev.6/06 Page 12 of 13 Massachusetts Department of Environmental Protection Bureau of Resource Protection -Waterways Regulation Program x232409 Chapter 91 Waterways License Application -310 CMR 9.00 Transmittal No. Water-Dependent, Nonwater-Dependent,Amendment Appendix C: Application Completeness Checklist (cont.) ❑ Water Quality Certificate: if applicable, pursuant to 310 CMR 9.33, is included. ❑ Other Approvals as applicable pursuant to 310 CM 9.33 or,for the initial fling,a_list.of such approvals which must be obtained. Projects involving dredging: ❑ The term"dredging" means the removal ofmaterials including, but not limited to, rocks, bottom sediments, debris, sand, refuse, plant or animal matter, in any excavating, clearing, deepening, widening or lengthening, either permanently or temporarily, of any flowed tidelands, rivers, streams, ponds or other waters of the Commonwealth. Dredging includes improvement dredging, maintenance dredging, excavating and backfilling or other dredging and subsequent refilling. Included is a completed and signed copy of Part F of the application. Filing your Completed General Waterways Application: ❑ For all Water-Dependent applications—submit a completed General Waterways Application and all required documentation with a photocopy of both payment check and DEP's Transmittal Form for Permit Application &Payment to the appropriate DEP regional office (please refer to Pg. 10 of the"Instructions"for the addresses of DEP Regional Offices). ❑ For all Non Water-Dependent applications—submit a completed General Waterways Application and all required documentation with a photocopy of both payment check and DEP's Transmittal Form for Permit Application &Payment to DEP's Boston office. Department of Environmental Protection Waterways Regulation Program One Winter Street Boston, MA 02108 ❑ Application Fee Payment for ALL Waterways Applications: Send the appropriate Application fee*(please refer to Page 1 of the"Application"), in the form of a check or money order, along with DEP's Transmittal Form for Permit Application &Payment. Department of Environmental Protection P.O. Box 4062 Boston, MA 02211 "Under extreme circumstances, DEP grants extended time periods for payment of license and permit application fees. If you qualify, check the box entitles"Hardship Request" on the Transmittal Form for Permit Application &Payment. See 310 CMR 4.04(3)(c)to identify procedures for making a hardship request. Send hardship request and supporting documentation to the above address. NOTE: You may be subject to a double application fee if your application for Chapter 91 authorization results from an enforcement action by the Department or another agency of the Commonwealth or its subdivisions, or if your application seeks authorization for an existing unauthorized structure or use. CH91App.doc-Rev.6/06 Page 13 of 13 Town of Barnstable *Permit# Erpires 6 monthsfront issue date PERIWI-`Regulatory Services Pee Q tnxtasrea[.4 25 2010 Thomas F. Geiler,Director �0t ®'F BARNSTABLE Building Division fi Tom Perry,CBO, Building Commissioner ��". 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 5087'790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X=P_ress Imprint Map/parcel Number Property Address 7iq7— U4W_?)f YL/ td-1 f_— 6077/) T esidential Value of Work 15 oo0 - 0 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address �- �V� �.YIrJ 0 LAe--I _ Contractor's Name'Up(n /\A V Telephone Number (�T 7 3� 37�0 Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Chec e: am a sole proprietor. ❑ I am the Homeowner ❑ I have Worker's Compensation 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 �t �. � r�,�,, �� !� R.of doors Replac W ement indows/doors/sliders.U-Value �, 94*h1Dr 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 required. SIGNATURE: Q:\WPFILESTORMS\building pe t fOrmS\EXPRESS.doc j ,��.. 'fi.•✓/L6 U/O�I77/IItO�lZ2lLGliL.6fi� � +" .. Board of B�►ild►nRegulitto/ns andtira,� y r . N L►¢cnsc or reg►stration valid for indiuidul use onh HOME IMFROVEME�T CONTRACTOR � fors the CP'fahon d►re+ 1f found return.{o .'� '� 'hoard of Buil�►ng Regulkions gad St ndards — Registration — P 138368 Ashbu► r,r►>1301• !' . r iExp ;iofi�3/21=1s Tr#319 go�'on,A[a Or208 ' ULLEN BUILDIN , G&'REM`—ODE-'U N ►,�Y ��s' � ' I DOI IGLAS MUL�L`ENt ' r� �'ARM1/1(yt, M�'F U Sd3 tir "� r �t F+ d�vitl►oul Sig-nature i 1t k Adn +►1S �. �. IVlassachusctts- DcPa►tmcut of Public Silt'ct� ++ R4.ulations and Standards Boa!"d of Bu►ld►n,. ervisor License Construction Sup License: CS 8995 i. Restricted to: 00. , '• r DOUGLAS W .MULLEN 87 HICKORY HILL CIR ,' OSTERVILLE, MA 02655 Expiration: 112312012 ('ununis`iun`r - (Pr1 A }Yk, i Y�7. �IHE rpm 'Town of.Barnstable Regulatory Services BARNSTABLE, ' Thomas F. Geiler,Director v nuas. 63 q. i Aim f 6.3 Building.Division Tom Perry,Building Commissioner 200 Main Street,Hyannis, M.A 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete acid Sign This Section If Using A Builder 7, ?07-rt-e- FIB Y�n 0 , as Owner of the subject property hereby authorize - pV to act on my behalf, in all matters relative to work authorized-by this building permit application for. 2�2 LCy�N��f c,0v.� (till (Address of job) Signature of N4 Date Tat ' 14 660b[Q Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the •reverse side. Town of Barnstable WHE Tpty� o� Regulatory Services Thomas F. Geiler,Director RMWTABLE, t0"9' Building Division ojE0ta Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 rvww.town.b arias table.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: Zd L id number street vil ol . "HOMEOWNER": �T work hone al name home phone#{ P 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. DEFINI•TION OF HOMEOWNER Persons)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 buildine permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned "homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner `-Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of cbnstruction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when.the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. i To ensure that the homeowner is fully aware of his/her responsibilities,many comunities require,as part of the permit applicat m on, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. nAWPFI LFSTO.RMS\homeexempl.DOC The Commonwealth of Massachusetts Department of Industrial Accidents Office oflnvestigations 600 Washington Street ` Boston,MA 02111 l� www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le gib Name (Business/Organization/Individual): Address: Zr Q, QK 17z7 q City/State/Zip: A/ 7 M(I Phone4: K7--37,- -I Are you.nn employer? Check the appropriate box: Type of project(required):1.ElI am a employer with 4. ❑ 1 am a general contractor and I ployees (full and/or part-time).* have hired the sub-contractors 6. ❑ New.constrttction ,pK 2.Er I am a sole proprietor or partner- listed on the attached sheet.. 7, [remodeling ship and have no employees These sub-contractors have g, ❑ Demolition workingfor me in an capacity. employees and have workers' Y P Y• 9. ❑ Building addition [No workers' comp. insurance comp.insurance.$ �required:] 5. We are a corporation and its 10.0 Electrical repairs or additions ❑. 3.❑ I am a homeowner doing all work officers have exercised their I LE] Plumbing repairs or additions myself o workers' comp. right of exemption per MGL y [N p 12.❑ 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 41 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 and job site information. 'Insurance Company Name: Policy# or Self-ins. Lic.#: Expiration Date: . Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy:=mber 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 ruder the sand pen lties ojperjrrry that the information provided above is trite and correct. I Signature. 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 orHealth 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5. 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 einplo)'ee 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 moreai 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 i e; dwelling house of another who employs persons to do maintenance,constriction or repair work on such dwellng 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 pei-formance 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 d to carry workers' compensation insurance. If an LLC or LLP does have members or partners, are not require . employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or.license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact.you regarding the applicant'. Please be sure to fill in the permit/license number which will.be used as a.reference number. In addition,an applicant that must submit multiple 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 fiiture 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 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-Iv1ASSAFE Fax # 617-727-7749 Revised 4-24-07 www.inass.gov/dia TOWN OF,BARNSTABLEBUILDING PERMIT APPLICATION.., ""Application Map- Parcel"' "APp Ication # GZ Health Division Date Issued 6 ion Conservation Divisi on Application Fee Planning Perm' it Fee: Date Definitive:Plan Approved by Planning Board Historic - OKH Preservation Hyannis Project Street Address C-L-ArAt,1fE-1,i- toI)C- Village Address A/Kc- Owner CTeP, TIZY4,QGY, Telephone C506- Permit Request LeAOVE Two Cx-11)6-06 "TWO' Ai"Do W-S, C(,-o5,E W 0?r--N IA; k5 1A)STA-L-t- AlEyQ 5W1A1-LFY2,, APiD e4Z S E-^4 U�J LT-5, Square feet: 1 st floor: existing proposed 2nd floor: existing proposed aj Totai-new Zqh,ing District Flood Plain Groundwater.Overlay c-5 -< Project Valuation Construction Type CO Lot Size Grandfathered: Q Yes 0 No If yes, attach sup orting documentation. C-n Dwelling Type: Single Family Two Family Q Multi-Family(# units) Age of Existing Structure Historic House: U Yes Q No On Old King's Highway: CJ Yes U No Basement Type: 0 Full Ll Crawl LJ Walkout Q 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: L3 Gas Ll Oil El Electric LJ Other Central Air: Q Yes Q No Fireplaces: Existing New Existing wood/coal stove: U Yes U No Detached garage: J existing C3 new size_Pool: LJ existing J new size Barn: LJ existing Ll new size Attached garage: LJ existing Ll new size —Shed: Ll existing 0 new size Other: Zoning Board of Appeals Authorization El Appeal # Recorded 0 Commercial L]Yes Ll No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name J)OU PAV LA-e AJ Telephone Number SOF -73 3-3 2-If Address f(t), we Iz. ,;lq License AM WOO Home Improvement Contractor# f%C6 Worker's Compensation # G3 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO -T)UM SIGNATURE A DATE_ FOR OFFICIAL USE ONLY APPLICATION# , DATE ISSUED ' r MAP/PARCEL NO. r ADDRESS ` VILLAGE OWNER i DATE OF INSPECTION: h FOUNDATION FRAME �116IDp �W9-4 ' fi INSULATION ` - • FIREPLACE ELECTRICAL: ROUGH FINAL -Y ! PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING I�1ath (.13. o5 a DATE CLOSED OUT. J r ASSOCIATION PLAN NO. I:a i` The Commonwealth of Massachusetts Department of Industrial Accidents 93 Office of Investigations' 600 Washingtdn Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): -AU(. l4V Address: ?.0 SOX t1-7 Y City/State/Zip: b-M°u S M 11,L3 rhone.#: SO #7 —3ZY l Are yoy.an employer? Check the appropriate box: Type of project(required): 1.uq/I am a Y emP to er with e 4. 1 am a general contractor and 1 ' " 6. 0 New construction employees(full and/or part-time).* have hired the stub-contractors ..2.0 I am a sole proprietor or partner-' listed on the•attached sheet. T. 0 Remodeling ship and have no employees These sub-contractors have 8."0 Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'.comp.•insurance comp. insurance.$ required.] 5. We are a corporation and its "10.0 Electrical repairs or additions 3.El 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' 13.0 Other comp.insurance required.] "Any applicant.that checks box 41 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 subcontractors 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: /��1PANJOE 5T)_k-7F_ Policy#or Self-ins.Lic.#: Expiration Date: /I IZ) Job Site Address: L' `AAOL-D hjpL City/State/Zip: Coil/ IT AAA Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure fo secure coverage.as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine tip 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 u der the pa' sand penalties of perjury that the information provided above i true and correct. Si ature: Date: V Phone#: -7 Lt 19 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#: I I i 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 tiustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced-acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7) states"Neither the commonwealth nor any of its political subdivisions shall . enter into any contract for,the performance of public work until acceptable evidence of compliance vrith the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractors)name(s),.address(es)and.phone number(s) along with their certificate(s)of insurance. Limited Liability Companies.(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete'and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit(license number which will be used as a reference number. In addition,an applicant that must submit multiple 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. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related fo 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 De.parhnent of Industrial Accidents Office of Investigations. 600 Washington Street Boston, MA 02111 Tel. #617-727-4900 ext 406 or 1-877-MAS.SAFE Fax# 617-727-7749 '• Revised 11-22-06 f www.mass.gov/dia Z tf2 Gam"^ ��- co✓� CaTU r i (CARED BY DATE 2 3 4 5 - 6 7 8 9 10 11 P(/AT-6 5 Ta PC, P, . 12 Z v5lN�j �GsTi��j la G_�oS� r�v v 5r�v 13 �, -T/y',-)V'L)4-rF J w 14 y, No eLEG77!�,is c oF, ''i LV An V3 IA/6 15 AVD'pov6l.€ 's�GK 5 16 17 j 1 18 19 - -1 20 - 21 22 f. UgIN6, C,L-&* r- t,v 051.AJ 5'T�r?(� 23 24 3, q'DDv+3�E5 25 26 ; 27 28 - 1 • t 29 30 31 j 32 33 34 35 36 37 38 39 0 l ` 41 42 x_43 44 45 46 47 48 " 49 50 51 52 53 54 55 56 12/02/2008 14:32 15087907955 GCEANSII)E-:•INSURANtE PAGE 02/02 12-02-00 01:64pp -fram-AIG +471 Sal 8699 T-229 P-001/002 F-514 <TOf'e7mum:5087"7955> •� y7' ,:tt��• ., ;.r 1-.,:r.:a1 C• , r` S.-'rM'y. ,f��1 ' r '�I',If�';,y;'l ' •:v�,, ,::i�' I�'.�, FS SjpL��SS I � :•' A i.� ;jam• •�. 'y::..t�- • '� :r'n_ 'Ipyp'1�r�.�q'•{ I j.i.�::. i �'1I 1 ®ry_L{p9�r�(1,'�7')�Y�p7��Tpp1��T� �r. '�!�rY''t'}�h.•.:. ,.�_},,:alp; S + ��D. .fT,::. •Jf •;':J�� ,�:��.��'; � .�J tJZ 1,\P�v!�..�� •�{['�,�p'��-fir�... 4•^ ��;'' w•, �'' '�rt r:.i:Sy::S:..�-).��, I.,i; ,)'�rRG�'1�I;r"1 �+ ,,.�� r•r q, ,o:' �'' I �: "at 'F.,'9'N:.. �� 'j. �1:t, �1,iI�}K w"i�1n.I `i•�Fr, :�Y�. u:r'r ,:��...J:' :!I='i: "- �,Y' ., ,rs:',.c''c'' •h r ti PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Oceenalde Insuf2flee Agency Inc HOLDER.THIS CERTIFICATE-DOES NOT AMEND,EXTEND OR 82 West Main St ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW ' HyannlF,MA 02801 �- ' 130M W1ES AFFQRDINO INSURANCE COMPANY-A ' .= GRANITE BATE INSURANCE COMPANY INSURED Doug Mullen - Po Box 1274 ` Mamtows Mills,MA 02648,0ODO 4-- OVIE6i141fiP. -51' 'a'i73 l`Z•I:.��:'�. 'I�•.g:�� -.l! ,,,�:'j�d^! AG�R,.:i�,'i��.��., �f F:i�i :{'ill'. ^ ily',.�}:.��,r�,.,..% ,.. .�•�la:, ,,.y4�l.IL •KJ�';;' THIS IS"TO7dt0ttFY THAT TW0fOLIjMM11F INSURANCE UMD BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR 0}iE POLICY PERIOD INbICATED,NOT WITHSTANDING'ANY REQUIREMENT,TERM OR CONPITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO W HCH THIS CERTIFICATE MAYBE ISSUED OR MAY O&IrAIN,THE INSURANCE AFFORDED THE . POLICIES DBECRIBED HEREIN IS SUBJECTTO ALL THE TERMS,EXCLUSIONS AND CONDMONS OF SUCH POLICIES,LIMITS 6161" MAY HAVE BEEN REDUCED BY-PAIQ CL&I MS. TrP00 SURAN00 POLJCYlR11t9BR E TX: POLlCr TtON TT! A OQ 12MPLQYEN3 UAGI JTY I=PROPRIETON :j4,{ti l M''�+�p, 1►,s1' �;�, T' ARTOfiR@15XEClRNE t' .y;� '�-:• L+�" FICERBARF . i nLrl, cL0OME3 A NE111lOF 11/21/2008 1.1/ 1/2009 ATvroRrLt�xr9 TnEa - waagn noab.wafar 000s-m Oro. N AGcwENT S.y100,0 3EA96 POLICY LIMIT 4EASE EACH LOrEfe_ S 100 0 I�TOpI OPE - 'WNS EMICLESMPEOIAI.I ~IN6 _ 7 ?K•' E:THE WORXP.RS COMPENSATION POLICY DOES NOT PROVIDF.CovERAqjjVO$k=UG MUL.MN., CERTIFICATE HOLDER CANCELLATION, TOWN OF BARNST'ABLE SHOULD ANY OF THE AROVE OESORIFfiD POLICIES BE GNCELLED BEFORE TH@ ATTN:BLDG DEPT EXPIRATION DATE THEREOF,THE IBwwr.CDMPANY WILL ENOi m To►MIX.]Y 20D MAIN ST DAYS WRITTEN NUTATO nI8 eMYIPICATE}IOLDER W*=To 7Hi LEFT,BUT HYANN 18,MA 02801 FAILURGTO MAIL 6UCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON YHE COMPANY.In AGENT8 OR RRMCGENTATIW8. AUTHORIZED REPRESENTATIVE '✓�a "t�o�z:rxo�une��r'l� n�✓L��a.:atic�u,wlf ' rds License or registration valid for individul use only Board of Building Regulations and Standa .Ti. nd return to: before the expiration date. if fou T HOME IMPROVEMENT CONTRACTOR v Board of Building Regulations and Standards Registration: 138368 One Ashburton Place Rm 1301 �. _• Expiration: 3/27/2011 Tr# 231259 Boston,Ma.02108 Type: DBA MULLEN BUILDING&REMODELING e DOUGLAS MULLEN ^' _ 59 NOBBY LN. °"Q C` Not dalid without signature_.._.. _. WEST YARMOUTH,MA 02673 Admiaistrstar Bo*d o w�jng egu at�ods and Standards Construction Supervisor License t �► License: CS 81995 t. Expiration:-112312010 Tr# 15516 Restriction: 00' I DOUGLAS W MULLEN 59 NOBBY LN Commissioner W YARMOUTR MA 02673 ` �IME,q Town of Barnstable Regulatory Services anaNAB& $ Thomas F.Geiler,Director ,0� 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 6 G clLI I, , as Owner of the subject property hereby authorize T)©U(n /--A U t--h" to act on my behalf, in all matters relative to work authorized by this building permit application for. C.-WE Rb Corvcl (Address of Job) Signature of Owner ate Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORM S:O W N ERPERM IS S ION Town of Barnstable Regulatory Services BAM&FABM Thomas F.Geiler,Director ` AS& Building Division ArF p �r. Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: 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 dwellints of six units or less and to allow homeowners to engage an in for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER. Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\homeexempt.DOC I. Assessor's Office(1st floor) Map 005 Parcel 00�5 t Y93 Conservation Office(4th floor)(8:30-9:30/1:00=2:00) _ Date Issued —9s Board of Health(3rd floor)(8:15 -9:30/ 1:00-4:45) Fee Engineering Dept!(3rd floor) House# � � - �-. Q}tME -- Planning Dept.(1st floor/School Admin. Bldg.) BARNSTABLE. Definitive PI prove by Planning Board s 19 T s TOWN OF BARNSTABLE Building Permit Application Project Stree ess Village 7- Owner( �.� �� Gam/ Address rp2 yZ _Telephone Gf -. L1 206 f 'Permit Request p v R7-&/i�,g 40241,422, 'e"V247AJA&V.9 D7ul-V .First Floor square feet Second Floor square feet ' o� Estimated Project Cost $ y06 Zoning District Flood Plain Water Protection Lot Size Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use Proposed Use Construction Type Commercial Residential x,-' Dwelling Type: Single Family ✓ Two Family Multi-Family Age of Existing Structure Basement_Type:;' Finished Historic House AJo Unfinished Old King's Highway d Number of Baths No. of Bedrooms Total Room Count(not including baths) First Floor Heat Type and Fuel Central Air Fireplaces Garage: Detached Other Detached Structures: Pool Attached Barn None Sheds Other Builder Information Name 4,11n <:A l2 1;7; Telephone Number Address G�f.S� Al lr License# Qg&-Veg z 22-1 Home Improvement Contractor# �Y 22_7� A499rZkXD Worker's Compensation# -440:�3 b-t/ q s L/91 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 TO SIGNATURE _ ,¢6 DATE BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) FOR OFFICIAL USE ONLY PERMIT NO. - DATE ISSUED ' MAP/PARCEL NO. s ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME, - + INSULATION FIREPLACE ' ELECTRICAL: ROUGH w FINAL PLUMBING: ROUGH FINAL - GAS: ROUGH FINAL ' FINAL BUILDING t t DATE CLOSED OUT + + • t ASSOCIATION PLAN NO. F 1 ; I \ ✓/te 1Jow L O� ZtIGP.�d I I HOME IMPROVEMENT CONTRACTORS REGISTRATION oard of Building Regulations and Standards j One Ashburton Place — Room .1301 I Boston, Massachusetts :021.08 I I . HOME IMPROVEMENT CONTRACTOR I ____ __ ------- -Registration 100740 Expiration 06/23/96 Type — PRIVATE CORPORATION --7k I -HOME IMPitOVEMENT CONTRACTOR..•, a.A"istratios :I00740 "Capizzi Home -Improvement, Inc. i TYPO -'.'.PRIVATE CORPORATION••. Thomas 'Capizzi , Sr . i -Elpiration • •-06/23/96 1645 Newton Rd . Cotuit MA 02635-. i Capizzi Hone Improvement, Inc I Thous Capird, Sr. � W 4FgAW Newton Id. I I AmMsTRAmR - -Cotuit NA 02635 + Restricted to: 10 DEPARTMENTk1*9w�, DEPARTMENT 1r PUBLIC SAFELY _. ONE A511BUR CONSTRUCTION SUPERVISOR LICENSE I 10 - Role BOSTON; lisba: . Wires: 16 - 1 1 2 Tjoily poles ,CONSTRUCTION SUPERVISOR LICENSE leslricled Is: 00 Number= Expires: ��+_:e_ . OAVI1 N NEBO 'Rest r.itt ed f e: 00 CoMMrsMIM 100 PLUM H011OY RO I tALIIOUTH, NA 0836 ' _ THOMAS .X CAPIZZI JR 280 ,PERCIVAL DR a t W BARN.STABLE, MA 02668 The Commonwealth of Massaeh ksetts Department of Industrial,-t ccidents 600 Washington Street Boston, Mass. 02111 Workers' Compensation Insurance Affidavit cite erg-- phone it I am a homeowner performing all work myself. I am a sole proprietor and have no qne working in any capacity I am an employer providing workets- compensation for my employees working on this job. company name: address: City: phone#: insurance co. policy# R t am a sole proprietor. general contractor,or homeowner(circle one) and have hired the contractors listed below s�ho,have the following workers compensation polices: company name: address- city: phone#:4 insurance co -L �T / ��J�� policy# �� zAle b J %p 3,Vt- company name: address• may• phone#• incnrAnrP rn pof➢cy# Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a floe rap to S1-100.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER soda fine of S100.00 a day against me. I■sderstand that s copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verificatioa. l do hereby-certifj-under the pains and lties of perjury that the information provided above is true and correct Signature Date Print name Phone 0 Cconfact ly do not write in this area to be completed by city or town official permit/license# OBuilding Department oLicensing Board mediate response is required OSelectmen's Office C)Healtb Department n: phone 0;_ __ -- r'lOther (revised 1/95 P1A) The Town of Barnstable AM Department of Health Safety and Environmental Services N,At Building Division 367 Main Strut,Hyannis MA 02601 Off= SOSMO-6227 Ralph Cmssen F= 508-775-33" Building Commissior For office use only Permit no. Date • AFFIDAVIT HOME XMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL a 142A requires that the mrcconstruetion.alterations,renovation,repair;modernization,conversion, imprvvemertt..rento%al, demolition, or construction of as addition to nay pre-cCisting owner occupied building containing at least one but not more than four dwelling units or to straczsttes which are adjacent to such residence or building be done by registered contractors,with eatain eoccptions, along with other retluirements. sr Type of Worn: a-- R'oo� Esc. Cost j e= Address of Work o2zz Ovmer.Name: Date of Permit Application: 2-7 I hereby certify that: Registration is not required for the follouing rcmon(s): _Work excluded by law _Job under S1.000 Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH?UNREGISIE ED CONTRACTORS FOR APPLICABLE HOME DOPROVEN04T 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 = Registration No. OR .,_._ Owner's name . Assessor's office(1st Floor): �SVS=MUST B; 0 0 Assessor's map and lot number 00 ,� ODS SE i YNE t Board of Health(3rd floor): LJANCE Sewage Permit number 's—��.� 5 w CODE/AND Z BARSSTABLL, i Engineering Department(3rd floor): ENVIROMIM A F P R °oE AML r' House number �'1 0� * X T0VM jMLA110NS 1ob Definitive Plan Approved by Planning Board 19 . Barns able Co-'--va Y G APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only ��O TOWN , OF BARNST , ad SE PatV6 BUILDING-,'INSPECTOR APPLICATION FOR PERMIT TO ��"� ` `a v� ? Yn s P v� 01M 42 -- TYPE OF CONSTRUCTION 19 TO THE INSPECTOR OF BUILDINGS: The undersigned`hereby applies for a permit according to the following information: \ j Location Y,\'Y� �a e CO v e �� CIQ )� a T S Proposed Use o VIA `e- Zoning District Fire District �& Name of Owner Address Name of Builder Address Name of Archite�b 0 Address RC Y� Number of Rooms v Foundation Exterior Roofing � .C/!Q Interior Gam% 0 Floors - Heating Plumbing Fireplace Approximate Cost Area Diagram of Lot and Building with Dimensions Fee �� ID Sao � v � C . OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Construction Supervisor's License RILEY, JAMES T. No :32875 Permit For Build Addition j ° Single Family Dwelling Location 242 Clamshell Cove Road , Cotuit a• Owner James T. Riled Y� Type of Construction Frame Plot Lot Per mit-Gr ed May 5 , 19 89 en z _ atve f In on � 19 11711 19 -� low � r: r2 F 3' O r.. .-... ....... .!:,777777. n m U T, LIB7-- fill .4 'Z • 07' ;�7 Assessor's office(1st Floor): Assessor's map and lot number C%O.S�� moo*TN E r. WQ o Board of Health(3rd floor): d ro Sewage Permit number v Z BL"sT,ABLL i Engineering Department(3rd floor): / �o NAsa House number �'1 -Yi 3639- Definitive Plan Approved by Planning Board 19 0 ra APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only TOWN OF BARNSTAB�LE BUILDING INSPECTOR APPLICATION FOR PERMIT TO TYPE OF CONSTRUCTION �j/yC� GyijjrfQ v G� 19 / TO THE INSPECTOR OF BUILDINGS: The undersigned thereby applies for a permit according to the following information: 1 Location t'��'�� =1 c i f O v e -el , p r_ � J�fa s U 5 Proposed Use Zoning District Fire District i ' Name of Owner ,��.e ° �' 'e Address 4�2 t/ './/� / ?.lD PJ Name of Builder Address Name of Architect-b C Ic �A ° u e Address Ac "rZS Number of Rooms &,U- �- Foundation Exterior ( Roofing Floors 7tC/lA/r-e Interior Heating Plumbing (� Fireplace Approximate Cost Area Diagram of Lot and Building with Dimensions Fee a27i OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name � 1 � , G Construction Supervisor's License 1 �� RILEY, JAMES T. A=005-005 _ 'lam• " No 32875 Permit For Build Addi_ti�n Single Family Dwe 1in'g Location 242 Clamshell Cove, Road Cotuit Owner. James T Riley j Type of Construction Frame !` Plot Lot i s � s Permit Granted May 5, 19 89 Date of Inspection 19 I' Date Completed 19 i 1 . • i i I y v i� 0 t pp �' ��54 To RE1✓If'r/N TI- yt/i!r k' N uN0�5TUR t� _ -s 2)p/s7711V 'DItFSi T / T% -3� y r a�ca�— _\ �. � _. .., � r,. G'dx P 'R�.�=• ?�R Pis' - IF ol G✓M/7'CF�lS'7Zl tt`GF1J i-- r.�'�' !e;,N/Y ro -/V/i+["' �;-�vll'��4�"a• -fir" —�M1 ._.`__�_ �Cr/ - i� 1 \,` � ?�� WA NC s.�ilwJrtl.��-� • . � j�WEGL � i� �0% � \� \ Y • :�;��,/�j< Vj,.,.� 3¢-- _ c.63• S c�-53-�'y1/ /. -_ \ \ c.3. c•r3. 7- - F'LA/Y- _Lz• I-' `5� �� i 4,7- r OF M4:s 22,6it'Et►�� / /17�A t N T E N STc CG"✓sTi�:':� '�-/`! r . 2b c. /•=! OFTp�TO TOWN OF BARNSTABLE OFFICE OF STAsaaMAO& _ BOARD OF HEALTH Op 1639. `� 397 MAIN STREET ,oho aav�'• HYANNIS, MASS. 02601 To : Building Inspector From: Health Department Subject : Test hole and Percolation Test examinat • n of t -e oil at (Lot) (address) ( Village) was made on ,S - and found .to be (date) suitable for sub-surface sewage, at- site of test hole. Building Permit will not be approved or sewage permit issued. until Health Department receives two copies of plan showing building, sewage systems and all other details listed in Board of Health instructions to sewage applicants. This approval does not constitute a final decision - concerning the installation of a sewage system. All State and local Health" regulations apply to final approval . _a, (Signature) 6/20/75 �edDC4k- 1Assessor's map and lot number -,� 74 -� jEdTIC SYSTEM MUST BE Sl ` Eo° Sewage Permit number lF, ....... T, THE rod TO W N O F BARNS TA�$,L E 13, - j IAMSTikt, i t "�` s6},9 BUILDING INSPECTOR �p • `00 r: 0 YPY a' C f J 1 APPLICATION 'FOR PERMIT TO ..... ........................................................................ ................. TYPE OF CONSTRUCTION .. ........................................................... • .............. ./...f'L.............19 . TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the followinginformation: 11 o T . �vLocation .................., Y......�1/ ......sd �l.......� t...... I...................../6TKi ...... Proposed Use ° `�� Zoning District (/ r........................................Fire District C0 ��/ ..............`............... ...............................:..........v...�<................ I s �e S•1• /l� `�Z 2 �F�'sT/�e tf J� �'j,QSS o z 03 v Name of Owners... ... ....�.... /¢..................................Address j&� ................ Name of Builder/ld.S�P.. ../'r.. ( r ..L°�'ST�Address J�Q.cv.�.?aC..lBa' 1�.0.Yr�'. h ....11 Name of Architect @Cl ./T4v.S�......�NCe..:.................Address .��30 ?i'�/i! ...�/�2-0 N Number of Rooms ........ .......................................................Found ation .c�....�Y.. .7" .................................................. D t ....._............................Roofing .. . ... / �...........Exterior .V.-¢ R.7-/..C1 I...... �...� �SZA 4 !':T Floors ..................................Interior ................................................ .. .?. .............................................. Heating ....AT.....WA/.:Q ..".iP./.!.........Plumbing.�I. .�.,. 7`�cr .... ...... ......................................... Ar Fireplace . Ne ............................Approximate Cost '—' Definitive Plan Approved by Planning Board -------------------_-----------19_______ . Area .1�.�../.... ` -L o w 0 Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH .2 i G1 361 03` W N .8y I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. . � v Name . ....................... .......�,... —. .. .... ......................... L - Dr. & Mrs. James T. Riley No,].t:2-9........ Permit for ....... ' ........... 9 , ...........................� . .............................. Location ......I:ot••54... lamrtabe�.l ..�:��r. ..R. .,... Cotuit ............................................................................... Owner Dr. &...Mrs. . James. . ...T.....Rile�r .......... .... ............ . . .. . .. Type of Construction Wood ................................................................................ 5 - Plot ............................ Lot .....54..................... . A � . Permit Granted ....... ril .. ... .........7.............1976 Date of Inspection 6..7 �� Date Completed .�6..................19 PERMIT REFUSED ....................................................... .... 19 r ............................................................................... i a � ................. ..................................................... �,. 9 ............................................................................... Approved ................................................. 19 ............................................................................... ............................................................................... Assessor's' map, and lot 'number Sewage Permit number .............................. ............................. �QyOFTMET��`� TOWN OF' BARNSTABLE i MARNSTAXLE, i "b ,•� BUILDING INSPECTOR �o war°'• � . APPLICATION FOR PERMIT TO .....:.............:.......:.................................................................................::.............. TYPEOF CONSTRUCTION ...............................�............................. .......................................................................... TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the followinginformation: Location .. .�......... ..r.......' �.`...: .. ..�/.......L VE........:I n 4................. o T(J/ /...........:.l.f..: 5...................... Proposed Use ... '1 R' aM''.............................................................................................. ........................................ ............. Zoning District ` 1........................................................................Fire District . t f -r/�tif A 5.1. ,?V C X Address �.�..q,�F y.S T N e .44A ,DA.1/o-Q /IIASc o 2 03 0 Nameof Owner,. .:..........:.... ..:.. ............. ^ .............. Name of Builder ? o {!„TR/ P7T r�T�!!? (ati57 Address ::.. .: ��• /a�-- n"tY-,V Lo /7,4 ?:•�?Z- Name of Architect A0 (A/ ou PP 1,C Address �2,0 )�7,4 . � Xe,T9i'i 6,4 r-S o/>2-o ...............................a ............................... ...................................... Number of Rooms �.......................................................Foundation .Cd•� CYv ........... .................................................................... ►%� / .�i anti Exierior ...........,F...r..i... �................. ..+...'....`....................................Roofing ... 5. 1..... ....................................................... FloorsInterior icn l,� ................................................................................................................ Heating ..'.:..... ' v . -.. ?.:..i ........Plumbing ..: ?,d T-t.. r..'.......................................... Fireplace ' Q ........................................................... Cost 0 00. Definitive Plan Approved by Planning Board -----------_______------------19_______. Area .. ...... .. ... r` .' Diagram of Lot and Building with Dimensions �-�w 1N�T Fee I -��— _ _ ............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTHE-� I I ' i V ' to ! "+ I W 8 I hereby agree to conform to all the Rules.and Regulations of the Town of Barnstable regarding the above construction. Name . ::!..:•....:... ...-�............... .n ':................. � br F & Mrs. James T. Riley No ,.18294..... Permit for DY,gj.Z n«.................. k � o ..........................:�',za'. ............................... Location ....Lot,.S4 Clamshell Cove„Rd,,,,,, ...................C.n ttx z.t........................................ Owner ....Ax.... Type of Construction )..Wodd........................ Plot ......5.......-...... .5. Lot ......54...................... Permit Granted ....Ap r.i.l..................7....19 76 Date of Inspection .................................... Date Completed .................. ....................19 PERMIT REFUSED ......................... .............................. 19 .......... ...................... /. . ..... .... ... . .......... ...................... .....!'... . ......................... Approved ................................................ 19 ..................... ..................................... ........ J CERTIFY THAT THIS PLAN HAS BEEN PREPARED IN CONFORMITY WITH THE RULES AND REGULATIONS OF THE REGISTERS OF DEEDS OF THE COMMONWEALTH OF MASSACHUSETTS. Professional Land Surveyor Date: Uj �o` w PROPOSED Z � STEPS o ^� 4 S BOTTOM w 4. a0 OF BANK SPARTINA PATENS 2 `+ & MIXED GRASES swum H�TERNlFLORA 2.5 SPARTINA AL 2.3 -0.5 -0.5 -a4 • • • •EDGE OF MARSH �,O 5G • MAW O p • • O -0.9 -0.8 -0.8 O L` ,+� 8' x 8' GRATED OARS ,n PLATFORM EL. 5.3' -1.5 �p� -14 1.5 -1.4 -1.3 -1.0 8" DIA. PULLY PILE -2.0 -1.6 -1.6 -1.6 -1.7 ^ SHOESTiQINC 5A Y -1.7 -1.6 -1.6 -7.7 -1.7 -1.7 -18 -1.7 -1.7 -1.6 -1.8 -1.8 PLANS ACCOMPANYING PETITION OF Of PETER M. PRYGOCKI & JOAN N JOH N SON PR6RgA TO CONSTRUCT AND MAINTAIN A PIER IN SHOESTRING BAY n ��ao.a4sa2 ° y BARNSTABLE (COTUIT), MA. �° �/sAL 0 10 20 DATE: FEB. 3, 2010 SCALE: 1"=20' SHEET 2 OF 3 A.M. WILSON ASSOC., INC. ELEVATIONS ARE BASED ON M.L.W. JOB NO. 2.1603.0 14'± FROM PROP. HANDRAIL PROP. 8'x8' PLATFORM MLW (AS REQUIRED)— o w EL. = 5.3' EXIST. z ' 31'± FROM MHW D WALKWAY W � N 0o o PROP. 8" DIA PULLY PILE z —— — — — — — M.H.W. EL.=2.5' - - - - - - - - - - - - - - - -- ��` - - M.H.W. EL.=2.5' --------- M.L.W. EL.=0.0 -------- ---- -- - ---- M_L.W. c� — -r-, PROP. o G� /A A /� /.�/, /� i\� •� \\ ACCOESS LAND IN G CD (n TYPICAL STAIRS EL.=5.3' o. O � EXISTING SLOPE 1 Q ZEU) Z 0 m 0 r D — o --1 -9 > TYPICAL PIER PROFILE o 0 O � HORZ. SCALE. 1 ,�10 o > o VER T. SCALE: 1 =5 A o — 0 � O O a' CiJ�/0� D r D1 N >W m D = O Z W 1 30 d > \ l � (T (—N O 2) ;v VOD r lJ N rr- r-X Q s W N frTl U) = m N c a r 0 —� m w Z Z n�rn rriA MCD cn z ON D W "rri D Cn _T mm O W ➢ � ( < N z v r � 1 CERTIFY THAT THIS PLAN HAS BEEN PREPARED IN CONFORMITY WITH THE RULES AND REGULATIONS OF THE REGISTERS OF DEEDS OF THE COMMONWEALTH OF MASSACHUSETTS. Professional Land Surveyor Date: COTUIT 0P� CLAMSHELL COVE ROAD ` ® SRO D L=9.2 9' 115.76' $ PARCEL ID: LOCUS A.M. 005-005 PETER M. PRYGOCKI & t�,�/w (O JOANN JOHNSON � ��? 242 CLAMSHELL COVE RD. �j��c COTUIT, MA. 02635 OPPONESSET 0 0 U Wa 3 BAY ' LOCUS MAP� 5E op O Qx_j n.dQ 2z o �X\ pECK rn o F2 to 0o C -H LO W 00CL PARCEL ID: O A.M. 005-004 m P O ROBERT J. & SL A SUSAN J. BOTHWELL p TOP OF 41 SPARHAWK PATH Q�-Q LANDSCAPE MARSHFIELD, MA. 02050 m= 3' WIDE PATH TIMERS z j osm m OM OF N SPARTINA PANS& MIXED RASES ,MHW 2.5 SPgR71Nq AL7ZRNIFLORA _ r t4Q/s� �P� 5 ,� p 3 MC W,p Op • • 'A 8' x 8' GRATED-H PLATFORM EL. 5.3' z RpgEf1T A. yG ORAK� R` J CIVIL Q a_ µo.0642 Q Sh'OESTF'INO 914 a 0 20 40 SCALE: 1"=40' PLANS ACCOMPANYING PETITION OF ELEVATIONS ARE BASED ON M.L.W. PETER M. PRYGOCKI & JOANN JOHNSON TO CONSTRUCT AND MAINTAIN A PIER IN SHOESTRING BAY BARNSTABLE (COTUIT), MA. DATE: FEB. 3, 2010 SHEET 1 OF 3 A.M. WILSON ASSOC., INC. JOB NO. 2.1603.0 i Revisions: '31 ± FROM MHW 2"X4" HANDRAILS & SIDERAILS(TYP) qo ysti9 / - , 11/23/09: Added distances from MLW FROM M W B DIA TIMBER /0 and MHW to gully pile and ' ' PILES 11' O.C. (TYP) '�} end of platform. sAnrruir PROP. 8'x8' PLATFORM PROP. HANDRAIL 4'-0" �. ROAD 12/02/09:Changed stairs to run = 5.3' 2"X6" DECKING 1 7- EL. towards the North. {AS REQUIRED) WITH 1" SPACING(TYP) 3"X8"STRINGERS 4' PROP. 8" DIA PULLY PILE 16"0.C.(TYP) PIER ELEV. _ 5.3` 3/4 DIA. GALV. BOLTS(TYP o�h S/TE 20d GALV. NAILS(TYP) \ EXIST. WALKWAY 3"X8" CROSS-BEAMS .�.... .`.�.. .�.... .... ...� .�._ ....... ... .. / .. ,�... . ... . .... EACH SIDE OF PILE(TYP) M.H.W. EL.=2.5' ,� � M.H.W. EL.=2.5' 2"x8"BRACING PROP. LANDING AT ALL PILE BENTS{TYP) .'� EL. 5.3 POPPONEssEr .._.. _ _:.._.. M.L.W. EL.=0.Q' ..�......__.,_ _ r .. �. ..» .. .. .. ._.�.......r,..�... M.L.W. E L.=4.0' C� BAY 15' MIN. OR REFUSAL PROP. ACCESS STAIRS /i /� /i /i /i /i /i%. TYPICAL PILE EMBEDMENT 11 LOCUS MA ID Existing Conditions Survey By: EXISTING SLOPE NOT TO SCALE TYPICAL FIXED PIER SECTION SCALE: NONE DEED 8K. 22975 PG. 281 , BREldfAN SURVEYING & ASSOCIATES, LLC PLAN 8K. 223, PG. 39 (LOT 54) MuNrD SU::1WOR..0 kk'D GIM ENGMEW 140 MARION ROAD, i1ARMAN, MA 02571 VV TYPICAL VIER PROFILE Project Title: H 4R Z. SCALE: 1 „=10' VERT. SCALE: 1 "=5' NOTES: ELEVATIONS ARE IN FEET AND TENTHS ABOVE THE PLANE PIER NOTES CO' OF MEAN LOW WATER. MINUS FIGURES INDICATE DEPTHS #242 BELOW THAT SAME PLANE. 1. PILING TO BE NON—CCA TREATED. DATE OF SOUNDINGS: JULY 16, 2009 2. NO LEAD PILE CAPS ALLOWED. Clamshell NO EELGRASS OBSERVED. 3. MINIMUM 3/4" SPACE BETWEEN DECK SPACE. 4. GRATED SURFACE TO PROVIDE 60% Co VP LIGHT PENETRATION. LANDSCAPE NOTES Road ASSESSORS ID 005006 1. EXISTING PATH TO BE WIDENED TO 4' BY PRUNING. NO DISTRUBANCE OF ROOT MAT. TIMBER BULKHEAD 2. POISON IVY TO BE CONTROLED BY WIPING WITH ROUNDUP OR SIMILAR. NO SPRAYING ALLOWED. Co tuit ma i N87"32'50"IN 185'f o A, �� AP ti Prepared, For:bc / LANDINGOf EL. 5.3 00 of LADDERS 0 PETER M. PRYGOCKI 4' WIDE GRATED SLOpE WALKWAY 3' WIDE PATH ti6 N/F JOANN JOHNSC.IN �16 .1 T�Me RspsroAe PETER M. PRYGOCKI r� PRUNED AND 6 & JOANN JOHNSON NTAINED TO 4' h ,y0 CY, 20 Rascally Rabbit Road $ DIA. ° �,d 242 CLAMSHELL COVE ROAD Morstons Mills, MA _ ASSESSORS ID 005005 Q 02648 P PULLY PILE ac P DEED BK. 22975, PG. 281 �0 1 PLAN BK. 223, PG. 39 (LOT 54) 6 6 ,1 54'� a�t w �p�` , �' PROPOSED n o w r M ¢¢ STEPS w a a z a �, O A. R Wilson Associates Inc. /, GRATED cO ti o LAWN rLO V PLATFORM E 5.3 z© r o 6 0 608 420 0702 / FAX 420 0705 LANDSCAPE 4 '�° Z .,J �z o TIMBERS r t;. 1 A cc � tip`^. . ,. _ p� Cn � Drawing Title � z � 5p ,•r' /" ` 1� p •r '� � 11 LAWN J dob12 tJ a � Pier N87'32'S0"W 185 , 1 ,1• o erm ASSESSORS ID 005004 aiiOF h c ROBERTA DRAKE CML No 41642 y Scale:1"— 20' 9 F` /STMME 0 10 20 30 40 50 FEET Oq EXISTNG PIER Date: October 29, 2009 Drawing No. Design: R.D. Check: Drawn: R.D. 1 Job. No.: 2.1603.0 Lost Rev.:Dec. 2. 2009 Prygocki ' n ' GENERAL NOTES AND MATERIAL SPECIFICATION 1.All workmanship to conform to the requirements of the Massachusetts State Building Code,lateFt edition. - -- 2.Structural Design Loads: Dead Loads:Actual Weight of Building Components Live Loads: Decks and Balconies=60 psf Wind Load: Criteria used for 110 MPH $xposure C 3.Timber Framing: a.Pressure treated timber(P.T.):Southern Pine with Fb=1300 psi,E=1,600,000 psi,or better. b.Laminated Veneer Lumber:Parallam(PSL):All PSL shall be min. 1.9E ES with Fb=2900 psi,E=1,900 Us Fv=285 psi, Fe_per750 psi,Fc_par=2900 psi. Note that Microllam and Parallam maybe used interchangeably. ' ry 1. Deflection Criteria: Ll480 Live Load,L/360 Total Load 4.Metal Connectors: As manufactured by Si-gipson Strong-Tie Co.shall be handled and installed per manufacturer requirements,with all nail holes filled,with the size nail as specified by mfgr.or herein. 'b CJ 5.Bolts: �._ -n Bolts in wood framing shall be standard machine bolts unless noted otherwise.Bolt holes in wood shall be 1/32".larger than - co rm bolt diameter.Bolt heath and nuts shall bear on standard malleable iron washers,or square plate washers.All nuts shall be retightened at completion of job. - 7 � plywood edges to this);locking Co 6.Nailing Schedule: All nailing shall be in accordance with Appendix 120.Q,unless noted herein specifically. a.All nails shall be common wire nails. b.Sub-bore where, r-nails tend to split wood. �� 5 � �, - — 22oo,10 _ - -��s t✓ rrr1 - 1 3-z�tb. 2-zxjo V 1J e, Chi F,r� Z- x J l 1 PiT1 = x /o —� on ' JU i ►T. 2�2yxI0 aR ' I 40 • 1 I l I fiTc Zlc (o- 1��,{�-��t � _— _�� --��•1-'G��T��I��I_Z�I;1-- • 4 1 PTAYf"_Z: est l s-�yts�g — �c� 1 MICHELE 'G o �1 CUUILO R�1 ; O No.34774 U • V u - STRUCTURraL _ -- -- _ _ _APPROVED BY:[DA AMS-ri t-p _ DRAWN Br REVISED p— - - ---- p- ----- -— -- ----—. 12r - I L-L c o =lzD i—�.o-T-vim 1-14- — _ MICHEL,E... CUDIM P.E. t ------ - -.---:._3_l4. L _-� -'------_-__-- - Consulting -.Structural _En loser - - --DRAWING NUMBER =-�-►�rt�L-�-�I� �o-r�PIS�= -t��=r. =G _ _ 123 Cottonwood Lone, Centerville, Massachusetts 02632 N- -