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0141 SPUR LANE
/All a e I ALTERNATIVE WEATHERIZATION BUILDING DEPT. SEP 0 8 2020 Date: rd a-D TOWN OF BARNSTABLE Town of Barnstable 200 Main St. Hyannis, MA02'6001 Re:Permit#b—�" Village: The insulation%weatherization work at['[['[[ V has been completed in accordance with 780CMR. I Regards, I Timothy Cabral, President CSL-105454 I I 58 DICKINSON STREET FALL RIVER, MA 02721 (508) 567-4240 ALTERNATIVEWEATHERIZATION@GMAIL.COM Town of Barnstable Building LC�L& Post This Card So That it is Visible From the Street-Approved Plans Must be Retained on Job and this Card Must be Kept v� f6}p ,� . Posted Until Final Inspection Has Been Made. Permit 'D En--1. Where a Certificate of Occupancy is Required,such Building shall Not be Occupied until a Final Inspection has been made. Permit No. B-20-1938 Applicant Name: Timothy Cabral Approvals Date Issued: 07/24/2020 Current Use: Structure Permit Type: Building-Insulation-Residential Expiration Date: 01/24/2021 Foundation: Location: 141 SPUR LANE,MARSTONS MILLS Map/Lot: 027-112 Zoning District: RF Sheathing: Owner on Record: BOLINDER, MATT D& DEVAN M Contractor Name: TIMOTHY CABRAL Framing: 1 Address: 141 SPUR LANE Contractor License: CS'=105454 2 MARSTONS MILLS, MA 02648 Est. Project Cost: $4,999.00 Chimney: Description: Air sealing,fg for damming and KW slope,blown in cellulose for Permit Fee: $85.00 attic, insulate existing door,propavents,soffit vents,vent bath fan Insulation: to roof,blower door and cst. Fee Paid: $85.00 Date: 7/24/2020 Final: Ct Z® Project Review Req: • � ���`�=-�--_' Plumbing/Gas Rough Plumbing: \Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months afterAssuance. All work authorized by this permit shall conform to the approved application and thesapproved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the Final Gas: work until the completion of the same. I }� - f{ Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Minimum of Five Call Inspections Required for All Construction Work: Service: 1.Foundation or Footing 2.Sheathing Inspection Rough: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy i Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL-c.142A). <<- Fire Department Building plans are to be available on site may_ „ ' All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: J �`w Town of Barnstable Building Post This Card So That it is Visible From the Street-Approved Plans Must be Retained on Job and this Card Must be Kept,. �+ M'B& Posted Until Final Inspection Has Been Made. "i Permit i63p.R � Where a Certificate of Occupancy is Required,such Building shall Not be Occupied until a Final Inspection has been made. Permit No. B-17-4092 Applicant Name: Neal Holmgren Approvals Date Issued: 12/11/2017 Current Use: Structure Permit Type: Building-Solar Panel-Residential Expiration Date: 06/11/2018 Foundation: Location: 141 SPUR LANE, MARSTONS MILLS Map/Lot: 027-112 Zoning District: RF Sheathing: Owner on Record: Devan and Matt Bolinder Contractor Name',- NEAL F HOLMGREN Framing: 1 Address: 141 SPUR LANE ; Contractor License: CS-088921 2 MARSTONS MILLS, MA 02648 Est. Project Cost: $ 15,592.00 Chimney: Description: Installation of 15 Lg 330watt solar modules flush mounted onrear i Permit Fee: $129.52 of building.4.95kw 225sgft Insulation: Fee Paid:` $129.52 a— oZ3— Project Review Req: y - _b .f Date: / 12/11/2017 Final: Plumbing/Gas Rough Plumbing: i I - — — ` Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. All work authorized by this permit shall conform to the approved application and the'approved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the Final Gas: work until the completion of the same. -� Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Minimum of Five Call Inspections Required for All Construction Work:; Service: 1.Foundation or Footing 2.Sheathing Inspection Rough: 3.All Fireplaces must be inspected at the throat level before firest flue _lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT � �I r l a- l t' 1'7 Town of Barnstable KECEIPT 200 Main Street, Hyannis MA 02601 508-862-4038 Application for Building Permit Application No: TB-17-4092 Date Recieved: 11/29/2017 a -a J Job Location: 141 SPUR LANE, MARSTONS MILLS � � � o Permit For: Building-Solar Panel Residential rJ Contractor's Name: NEAL F HOLMGREN State Lic. No: CS-088921 Address: , EAST SANDWICH, MA 02537 Applicant Phone: (508) 744-6284 (Home)Owner's Name: Devan and Matt Bolinder Phone: (508)815-2655 (Home)Owner's Address: 141 SPUR LANE, MARSTONS MILLS, MA 02648 Work Description: Installation of 15 Lg 330watt solar modules flush mounted on rear of building. 4.95kw 225sgft Total Value Of Work To Be Performed: $15,592.00 CP Q I � Z Structure Size: 0.00 0.00 0.00 N a Width Depth Total AreaO r" I hereby swear and attest that I will require proof of workers'compensation insurance for every contractor,subcontractor,or other worker before he/she engages in work on the above property in accordance with the Workers' Compensation Act(Chapter 568). I understand that pursuant to 31-275 C.G.S.,officers of a corporation and partners in a partnership may elect to be excluded from coverage by filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to accept coverage. I hereby certify that I am the owner of the property which is the subject of this application or the authorized agent of the property owner and have been authorized to make this application. I understand that when a permit is issued, it is a permit to proceed and grants no right to violate the Massachusetts State Building Code or any other code,ordinance or statute,regardless of what might be shown or omitted on the submitted plans and specifications. All information contained within is true and accurate to the best of my knowledge and belief. All permits approved are subject to inspections performed by a representative of this office. Requests for inspections must be made at least 24 hours in advance. Signed: Neal Holmgren 11/29/2017 (508)744-6284 Applicant Date Telephone No. Estimated Construction Costs/Permit Fees Total Project Cost : $15,592.00 Date Paid Amount Paid Check#or CC# Pay Type Total Permit Fee: $129.52 11/29/2017 $79.52 XXXX-XXXX-XXXX- Credit Card 2197 Total Permit Fee Paid: $129.52 11/29/2017 $50.00 XXXX-XXXX-XXXX- Credit Card 2197 1 THIS IS NOT A PERMIT TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parc Application V� 1 el # Health Division Date Issued Conservation Division Application Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board V Historic - OKH _ Preservation/ Hyannis t Project Street Address � dit(l Village Owner 1 i i Address sy Telephone_ ��, � ���r-?���� coAsF�d o.A� .Permit Request ` C �D:�b Q� Oss�)e_d and TV_\(2Ahq)Q Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type2. Lot Size Grandfathered: ❑Yes ❑ No If yes, attac'2s�upportirag-d000Enentation. i � F Dwelling Type: Single Family Two Family El Multi-Family (# units) ? c Cap i Age of Existing Structure Historic House: ❑Yes YG On Old King',s Highwe�: ❑%s ❑ No Basement Type: 3 ull ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sglft) rn Number of Baths: Full: existing new Half: existing e 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 ❑-I Igo Fireplaces: Existing Q New Existing wood/coal stove: ❑Yes 2l0 Detached garage: O 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 O]Rq j WNER Name QA\N`5Q(1 Telephone Number �_7m�� 1 � Address C7ej0Q Q1 SAC License # Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FS- b c A ' FOR OFFICIAL USE ONLY APPLICATION# t DATE ISSUED MAP/PARCEL NO. s t s ADDRESS VILLAGE OWNER ;-DATE OF INSPECTION: ,F FOUNDATION.. ' FRAME INSULATION k ` FIREPLACE EOECTRICAL: ROUGH FINAL ' PLUMBING: ROUGH FINAL GAS: ROUGH FINAL f � FINAL BUILDING �y9/0 f� DATE CLOSED OUT t ASSOCIATION PLAN NO. `l 4 1 f �i The Commongvealth of Massachnsem Department of Industrial Accidents Office of Investigations ' +600 Washington Street Boston,MA 02111 t mnv.mass go►1dia Workers' Compensation Insurance Affidavit: Btalders/Contracturs/Electrician&d%mbers Applicant Information Please Print Legibly Name Address: City/Stat&Zip: Phone#: Are you an employer?Check the appropriate boV Type of project(required): 1.El am a employer with 4. . I am a general contractor and I 6_ ❑New construction employees(full andlor pact-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the.attached sheet, y- ❑Remodeling ship and have no employees These sob-contractors have g_ ❑Demolition working for mein any capacity. employees and have worms' 9 ❑Building addition [No workers'comp.insimnce: comp.insurance.2 ❑Fl 5 ❑ We are a corporation and-its 3.❑ I lU- Prtrirnl repairs or additions am w homeowner doing all wank ed.] . officers have exercised their I LE]Plumbing repairs or additions am a 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 regwred.l 'Any.applicant that checks box#1 also U out the section below showing their woakere compensation policy iofnrmation- 1 Homeowues who submit this affidsvit inibcatiug they are doing all walk and then hue outside conttacmrs mast submit anew afdn"indicating sushi ZContmcmrs thatched this book now attached=additional sheet showing the nsme of the sub-camraclon and state whether or not those entities hsve employees. ifthe sub-contractors bare 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 informadem Insurance Company Name: Policy#or Self-ins.Lie.#: 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 foe up to$1,500.00 and/or toe-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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verffication. I do hereby r 'ns andpenalties ofpedimy that the information provided above is true an correct e: Date: Phone#: - LA O,,(ficial use only. Do not write in this area,to be completed by city or town officid City or Town: PermitUcense# Issuing Authority(tackle one): 1.Board of Health 2.Building Department 3.City/Fown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone 9: 6 O OP Cl� ' � � Cl I RECEIPT • 11 0 00100 TREASURER'S CASH ' - 01 433190 WIRING PERMITS - 30.00 1 RECEIPT • 30.00 6 00100 -?REASURER'S CASH ' 01 43315CF BUILDING PERMITS - 35.00 RECEIPT • 11 00100 TREASURER'S CASH 01 433150 BUILDING-PERMITS -r 35.00 RECEIPT • •1 5 0100 TREASURER'S CASH 1 433150 BUILDING PERMITS 160.00 Page 28 Town of Barnstable • Regulatory Services i &ARNSTAstr.r. • Thomas F.Geiler,Director 6,sq. 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 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATTOK- number `,�street Q.�(/ lvillage "HOMEOWNER": 3n re �Nc I 8- J mane r� home phone # work phone# c�Q.X Y CURRENT MAILING ADDRESS:_C J� IJ�Vs � "an ssQ 6 \U G: 02 0Ut Isk city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building-permit. (Section 109.1.1) c ' The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"ho eowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection pro es ents and that he/she will comply with said procedures and requirements. Signature o eo 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. C:\Users\decoUik\AppData\Loca1\Microsoft\Windows\Temporary Internet Files\ContentOudook\QRE6ZUBN\EXPRFSS.doc Revised 053012 I r Town of Barnstable Regulatory Services A Thomas F.Geiler,Director 1639. Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit (Address of Job) *Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner Signature of Applicant Print Name Print Name Date Q:FORM&OWNERPERMISSIONPOOLS 62012 . . !_ OK DETECTORS �VIRWFDoop r- .ir! 1 E I I ABA��NSTMI-E IBATE,13 . EllARTMENfi.. TARE REgU1REb FOR PEAMITTD� C , orpj ,.I � � , ! 1. ;.. . a�•. i I I i i CTORS VI E E EW D BARNSTABL�BUI DING DEPT. D E FIDE D�PAR1'MM'NT DATE :SIGNATURE'S ARE REQUIRED FOR PERMITTING • ;. �. , ,...• � • . ,--.,... . ' � lam' �I. �. , ' . I i 1• - - I ;. .. ! IMPORTANT UPGRADE REQUIRED ' t I ' S•i-0.1rs ! 1 VIP , ; cTA BUI' 1N I i 1 1 i I q•CO E REOU!R 6•THE UPGRADING OF ' I lA+ ,� , SMOKE DETECT RS OR THE NTIRE DWELLING WHEN L wir �2e�,�j I ` p J• -; i " I I• I ' !'! Y� t i. ONE UR.MGI,RE S�EEPfNG AREAS ARE ADDED OR CREATED. S GATE EPA A '7 I •PEROAIT IS• REQUIRED FOR THE f i I i .'� I r, ; NSTA CATION O�SMOKE D'ETEC70RS-THE ELECTRICAL ERIA`T DO •N T-SATISFY TH19 REQUIREMENT Sir NojS 1 {�H nn7 Spar :`wo 1 I I I ! I �I A Ihr 3i ss 1 i I MOK•t DETECTORS: OVIRWED . �...,2Q{ AUG S ' Z y � I ? i BA NSTABL 8 IL ING;DEpt bATE, t:,t Apt9: :12 _FIRE Di PARTMENT.. .,. , bAT� j I �,,�,,,.aa.r �•� ! $OTH SIGNATUR S ARE REgUIREb FOUR PERMITTING C) I • � •� DIU�'S C i�1 D�VI�� 74 .. i .. .. � .. ...'.. I, •ram.—.,. '� �' ' i � � ' � C A (Zsplo� i 1VIr�� I.... .:........... I I i . Sir A-Sftke, �►� r? ??T c�tTt�m Ur.. ..1to�"f 1�h . Spar- :Lvo. 1 � T� \ .. _......... _ ._ • _ ._ ..- __. _ ._._ __ .._ _.. ._. __ .-...._. .- _- _ .._._.._ T 71 : - - OL y7`pf1NETp��� Town of Barnstable ' Regulatory Services BARNSTABLE. ' MASS. t6,9. A, Building Division pTEO MAC 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Inspection Correction Notice Type of Inspection Location /yI Permit Number ;-7 0 3 O y 7 d Owner e-,4iV;6 i5 <9oK DO-A J Builder 5ALa(� One notice to remain on job site, one notice on file in Building Department. The following items need correcting: ct / Z c ge s spy a ------------------ i l frs r • i. Please call: 508-862-4for re-inspection. ' Inspected by Date TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application Health Division Date Issued 1 Conservation Division Application Fee Planning Dept. Permit FeeA-36- Date Definitive Plan Approved by Planning Board Historic - OKH Preservation / Hyannis Q Project Street Address !S 1XE LQL�e- Village M Oi 5-yofyS �,A 1 1 XS Owner `IF�p su. nn Address Telephone Permit Request to tO I'e� gLTa 'd'1 ukoc1 f srnoyneS Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District .)oco Flood Plain Groundwater Overlay Project Valuatio a Construction Type Lot Size / Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family [tJ' Two Family ❑ Multi-Family (# units) o _= o ? � w Age of Existing Structure Historic House: ❑Yes ®'No On Old King; Highwa,(�t- ❑Y2s o O -L r-- Basement Type: Y(ull ❑ Crawl ❑Walkout ❑ Other i T' Basement Finished Area (sq.ft.) Basement Unfinished Area(sq ft) cn Number of Baths: Full: existing �2- new Half: existing now Number of Bedrooms: � existing _new �v T Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes t No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current'Use -- Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name \ Telephone Number --7K"'-1 1�3 1�4b Address 1 H l�fh 3' �n License # k-AQ< tCN15� _6tL,\ \\S t—kfk Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO ouke-.6 secu�C-Q- - SIGNATURE DATE ` " J 1 FOR OFFICIAL USE ONLY a t APPLICATION# DATE ISSUED MAP/PARCEL NO. J ADDRESS t VILLAGE OWNER j DATE OF INSPECTION: FOUNDATION FRAME Y. INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL ' GAS: ROUGH FINAL FINALBUILDING 0 7-3 6 DATE CLOSED OUT ASSOCIATION PLAN NO., — ! " "SMOKE DETECTORS D V. Yk TABLE BARNSTABL B IL•ING;DEPf 4ZBATE. ; . i ! ; ' ; I � ���-�•� ! I ROTH SIGNA�TUR S A Of RE REEq IREO FOR PEfdM NG I .. .i. I 1. i . . ' .... .... ! .. .. I.. � .. .. I �I I r I_.._r ! ' y W i I<1VIr��A ��i'C" J Sir J i _ ...; .. �?'t0.. ,�.7r�,�P.Yh✓y T �� {,�GfiT'tli7� U ,, ..�.�.ti ..S-•f rS4'Ir?u � 1,; C. .�►• (°p i I : ' r : 1�I Spar :� .. 1 . ;'n ; . Jun 2713 08:47a Dominic Ingemi 5084552361 i : l a� : _... .... _..._..._.:. . _:. . _ .. . .. ..._....._..__. ._._ .. -- -.._... I The Cammonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gou/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectricianvTlumbers Applicant Information I Please Print L,exib Name(B .on/Individnal): 00-fn 1 n\ C Ad&ess: 0 o 7o3 City/Stat&Ztp: Phone 4- °7�l— 3 R9— C yz 6 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 6_ ❑New construction employees(full andlor Part-time)-* have hired the sub-contractors 2. I am a sole proprietor or partuer- listed on the attached sheet: y- ❑Remodeling ship and have no employees These y- �a have g- ❑Demolition working for me in any capacity. comp-inSs UCanoe.I and have wenixrs' 9. ❑Building addition [NO workers.*COIDp.insurance OIDp_insurance., 5. ❑ We are a corporation and its ME]Electrical repairs or additions required_] 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself [No workers'oomp_ right of exemption per MGL 12.❑Roof repairs insurance required.]f c.152, §1(4),and we ha%m no employees.[No workers' HE Other comp.insurance required]; •Any applicant that checks boa#1®st also fill out the section below showing their worriers'compeusafm policy information- Homeowners Homeowners who submit ffiis affidavit mdiczt mg they are doing all wean and the,bire outside contractors mast submit a new affidavit indicating such_ (Contractors&M cbera this boat mast attached au additional sheet slowing the name of the sob-comUBU rs and state whether or not those enli tks have employees. if the mob-contactors have employees,they must provide their workers'camp.policy number. I am an employer that is providing t►rorkers'compensation insurance for my employees. Below is fhe policy and job site information. Insurance.Company Name: Policy#or Self-ins Lic.# Expiration Date: aalaff&. Job Site Address- I CitylState/ - 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 certi nder the pains a penalties of perjury Mat the information provided alone is hue and carrel Si tore: Date: 3 Phone#: 7 �' —G 2 Official use only. Do not write in this area,to be completed by city or town official. City or Town: PermitlLicense# E60ther ng Authority(circle one): ard of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector act Person: Phone#- - 6 CERTIFICATE OF LIABILITY INSURANCE FDOA/26/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: ff the Get Hveto holder Is an ADDITIONAL INSURED,the pollcy(Ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this oertl does not confer rights to the coMcaLe holder In lieu of such endorsernent(s). PRwucER (781)828-8463 Ext. YcDeld Insurance Agency PHONE House Account ME Na PO Box 211ADDRESS: Canton, MA 02021 I S AFFORDerG COVERAGE NAIC• INSURED INSURER A:ARBELLA PROTECTION Dominic Ingeni INSURER0: 196 Tiffany Street INSURER C: Attleboro, MA 02703 INSURERD: INSURER E- INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. lkSR ADM SUM LTR TYPE OF INSURANCE iffn lam POLICY NUMBEIR PWAMNYMI O r ExP Ulm GENERAL LIABILITY EACH OCCURRENCE $ 600.000 COMMERCIAL GENERAL LIABILITY S 100,000 CLAIMS-MADE 0OCCUR MED EXP one S 61000 A 8500048389 08/25/12 08/25/13PEIRSONAL sADVIILIUIRY $ GENERAL AGGREGATE = 1 ONO OOO GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPADPAGG S 50 000 POLICY 7JECT- Loc ; AUTOMOIRLE LIABILITY OOMBINED SINGLE UMR s (En accident) ANY AUTO HOMILY INJURY(Per person) S ALL OWNED AUTOS OWLY INJURY(Per aoddeM) _ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Paracoldent) s NON-OWNED AUTOS S rl UMBRELLA LUB OCCUR EACH OCCURRENCE 8 EXCESS LIAR CLAIMS-MADE AGGREGATE 8 DEDUCTIBLE i RETENTION f WORKERS COMPENSATION LAIC STATU- OTTE AND EMPLOYERS'LIABILITY Y I N ANY PROPFJETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT S OFROERIMEMBEREXCLUDED7 NIA (mandatory in wo E.L.DISEASE-EA EMPLOYEE $ ryes dsscrlbe under DE RIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT f DESCRWMN OF OPERATIONS/LOCATIONSI VEHICLES(Attach ACORD 101,Addhlone!Remerlm Schedule,N more spew Is regulred) CERTIFICATE HOLDER CANCELLATION ALLISON SCHNEIDER 141 SPUR LANE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISION& MARSTON MILLS MA 02848 AUTOO D REPRESENTATIVE 019W2009 ACORD MAP`-IMON. All rights reserved. ACORD 25(2009)09) The ACORD name and logo are registered marks of ACORD �t►+E Town of Barnstable Regulatory Services Thomas F.Geiler,Director 16��M,,�► 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 HOMEOWNER LICENSE EXEMPTION 3 Please Print a � of B LocATION: _number street village �HOMEowNFR�j: �1' �On Sr�'111�j( �� �i `'��l�,^ 1 �ff name ^ home phone# work phone# CCURRENT-MAILING-ADDRESS;, Ch,� C)c c rl C° '1 MG OaAa cam_ city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned."homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection proce gad equirements and that he/she will comply with said procedures and requirements. 'Signs -of-Hg eowner-----J V� 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. C:\Users\decollik\AppData\Local\MicrosoR\Windows\Temporary Internet Files\ContentOudook\QRE6ZUBN\EXPRESS.doc Revised 053012 i �VE11 . Town of Barnstable Regulatory Services snuvsTASM y� MA & Thomas F.Geiler,Director r EcA Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit (Address of Job) **Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner Signature of Applicant Print Name Print Name Date Q:FORM&OWNERPERMISSIONPOOLS 62012 f a 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 aMe-(Busin se s/organization/Individual): Address:`L A City/State/Zip Phone #: !Ar yoeuan employer?Check the approprialioy Type of project(required): 1.❑ I am a employer with i 4. ff d am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g. Demolition workingfor me in an capacity. employees and have workers' Y P tY• ►i� 9. ❑Building addition [No workers' comp. insurance comp. insurance. 10. Electrical repairs or additions �._,-tequired] 5. ❑ We are a corporation and its ❑ P <3 ❑'Il. am a homeowner doing all work officers have exercised their 11.❑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 submitthis-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 whetheror not-thos"e entities have-'-"-'I mployees. If the sub'_contractors_have-employee.sthey,must provide thermsworkers comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Belo nsw 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 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 cer(tify`under Ih pains and penalties ofperjury that the information provided above is true and correct -Sienature 1 N-, Date: Phone#: V 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 individual,partnership,association,corporation or other legal entity,or any twb or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to cant'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 bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations '600 Washington Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 - Revised 4-24-07 www.mass.gov/dia i ' I n� CERTIFICATE OF LIABILITY INSURANCE 6/28/20113 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT James Sullivan NAME: NuAlliance Insurance Group, LLC PHONE (781)769-5200 FAX (781)769-5201 C. AIC No 1420 Providence Highway ADDRESS:]sullivan@nuallianceins.com Suite 265 INSURERS AFFORDING COVERAGE NAIC# Norwood MA 02062 INSURERAMain Street America Assurance 29939 INSURED INSURER B.NGM Insurance 14788 TAGEN PLUMBING 6 HEATING INSURERC: 5 CHARLOTTE CT INSURER D: INSURER E: F'RANKLIN MA 02038-1901 INSURERF: COVERAGES CERTIFICATE NUMBERCL1362800602 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR TYPE OF INSURANCE A D BR POLICY NUMBER MM/DDY EFF POLICY EXP LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMA E RENTED PREMISES Ea occurrence $ 500,000 A CLAIMS-MADE a OCCUR MPT9826H /29/2013 /29/2014 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per.accident UMBRELLA LIAB HOCCUR CH OCCURRENCE $ EXCESS LU1B CLAIMS-MADE AG REGATE $ DED RETENTION$ $ B WORKERS COMPENSATION X STATU- OTH- AND EMPLOYERS'LIABILITYI ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 11000,000 OFFICER/MEMBER EXCLUDED? F NIA (Mandatory In NH) CT9676H /29/(13 F4/29/20141 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.JSEASE-POLICY LIMIT $ 11000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) PLEASE REFER TO ACTUAL POLICY FOR OTHER TERMS, CONDITIONS AND EXCLUSIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ALLISON SCHNEIDER ACCORDANCE WITH THE POLICY PROVISIONS. 141 SPUR LANE MARSTON MILLS, MA 02648 AUTHORIZED REPRESENTATIVE James Sullivan/JSULL ACORD 25(2010/05) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025 rgmnnsi ni Thn Amin l n2mn nnA Innn om ronicfarcrl m2rlra of Arnpiri r The e Commonwealth of Massachusetts Department of Indiustrial Accidents Office of Investigations ' +600 Washington&reet Boston,MA 02111 imm mass.gov/dia Workers' Compensation Insurance Affidavit Builders/Co ctors/ElectncianslPlumbers Applicant Information Please Print Legibly Name B _ onllndivithral): c Address: _!57 CitylStatt:JZip: !q i- Phone ik 'G Z Are you an employer?Check the appropriate box: T. am a contractor and I 3'Pe of project(r���: 1.a I am a employer with_� 4 ❑ I g�� 6. ❑New construction employees(full andlorpart-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling ship and have no employees These.sub-contractors have 8. ❑Demolition working for me in any capacity. employees andand have wo�ss' 9. ❑Building addition. [No workers'comp.insurance Comp-��� required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]i c. 152, §1(4),and we have no employees.[No worlaers' 13.❑Other comp.insurance required-1 'Any applicant that checks boa#1 trust also fill out the section below shooting the¢workmV eompen;adon policy informations i Homeowum wbo sabmit Buis affidavit indicating they ate doing all wod end then hue outside contmctozs mast submit a new affidavit indicating such. kontracmrs Stet check this boat must attached an addidnusl sheet showing the name of the sab-ca otwi rs and state whether or not those Entities have employees. If the sub-contractors have employees,they must pmvide their workers'comp.policy number. 1 am an employer that is providing workers'compensation insurance for my enq&yeea. Below is the policy and job site informatrom Insurance Comp any Name:�Aa Cn.- 1 ' Policy#or self-ins.Lic.#: �1 1:,� 0\(o-7 C 0 N Expiration Date: �1 2 LA Job Site Address: (- �� City/State/Zip- V Aa�5tcy '� m 1 I t' Attach a copy of the workers'compeasation 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. 1 do lteraby certify under the pains and penalties ofpedkty that the information provided a e is true and correct Si tune: Duke: 11-3 Phone#: Off"icial use only. Do not write in this area,to be completed by city or town official i City or Town: PermitflAcense# 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#• _ 6 l Commonwealth of Massachusetts `s SheetMetal Permit MapL2larcel Date: Permit# CO Estimated Job Cost.. $ ©QO e �, EI Permit Fee: $ Plans Submitted: YES Plans'Reviewed: YES NO Business License# - ' ant License# �'7_0 3 Business Information: Property Owner/Job Location Information: Name: R26' 20 -f- e r Soin Name: De_vef6,On,e 1 Street: P_ O_ g c;X ��( r Street:- Ay I c City/Town: r �r2 e i vy �'►�/1 City/Town: M^a ft 5,7ok1 M �lS Telephone: 7 7�— �?�O — l�i �( Telephone:/ Photo I.D. required/Copy of Photo LD. attached: YES NO staff initial J-1/0unrestricted license J-2/M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft. /2-stories or less Residential: 1-2 family Multi-family Condo/Townhouses Other Commercial: Office Retail Industrial Educational Fire Dept. Approval Institutional_ Other Square Footage: under 10,000 sq. f over 10,000 sq. ft. Number of Stories: Sheet metal work to be completed: New Work: Renovation: HVAC Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents Air Balancing Provide detailed description of work to be done: • f. NSURANCE.COVERAGE: have a current-liabil insurance-policy oc_its equivalent which meets the requirements of M.G.L Ch. 112 Yes❑ No ❑ f you have 1q ecked'Yes. indi(aA the'type of-coverage by checking the appropriate'box below. .k liability Insurance pol y (,� Other type of indemnity ❑ Bond ❑ )WNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit application waives this requirement Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent y checking this boxC],I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and ccurate to the best of my knowledge and that all sheet metal work and installations performed under the pbrmit issued for this application will be i compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation: YES NO � Progress Inspections Date Comments Final Inspection Date Comments Type of License: aster le ❑ Master-Restricted -. y/Town ❑Joumeyperson Signature of Licensee rrnit# ❑Joumeyperson-Restricted License Number* a$ ❑ Check at www.mass.govldol pector Signature of Permit Approval I Jun 25 13 08:49p TEDD CARLSON 508-64 -7246 p.1 02/19/2013 10:50 FAX 508 998 6331 CHERYL LORANGER INS ®002 CERTIFICATE OF LIABILITY INSURANCE DATE IMWOw^'' 021192D13 PRaoucr�Ii 508-SM-0512 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION CHERYL A LORANGER ONLY AND CONFERS NO FUGHTS UPON THE CERTIFICATE D OR CHERYL LORANGER INSURANACE ALLTERRRTHE COVERAGE AFFORDED 13Y THE POLI TIHIS CERTIFICATE DOES NOT CIESBELOW- 13 CROMPTON STREET ACUSHNET,MA 02743 INSURERS AFFORDING COVERAGE NAIC O I1Lf1iRE0 INSURERA, FARM FAMILY CASUALTY INS CO CARREIRO 3 CARLSON MECHANICAL CONTRACTING. INSURERS: INC. INSURER C_ P.O.BOX816 INSURERa E.FREETOWN.MA 02717 INSURERS: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TOTHE INSURED NAMED ABOVE FORTHE POLICY PERIOD INDICATED.NOT10THSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IRSR am POLICY NUMBER POUCYRFFECTIVE PCUVT OIPIRAYMN Tans OENERALUAMILITV EACH OCCURRENCE i 1.000,000 X COMMMARCNLGENERAL LUIBAIT' PREMISES fFj g=rMpW i cwrASNUDE —1x OCCUR 2012XO277 051241ZU13 OS/24l201� MEOE7� ane + i 5000 PERSONALA ACV PFJURY s 1,000,000 GENERAL AGGREGATE i 1 000,000 GEMLAGGREGATE UNIT APPLIES PER: PRODUCTS-COLPIOPAGO i 2.000,000 POLICY wpiLOC I AVTOLTOYILJGIMIALITr i O NU SINGLE LWr i ANY AUTO (Ea deriC ALL ONTVED AUTOS BooILrINJURr i SCHEDULED AUTOS IPw Dersm) FIRED AUTOS BOOLYWJURY = NON401NFED AUTOS (Ps►wddmO PROPEITYOANAGE s (Per aatlaenp GARAGE LASRJTY ALTO ONLY-EA ACCIDENT i ANY AUTO OTHER THAW EA ACC i ALTO ONLY: AGG i E%CFJSAMURELiAUASILR7 EACHOCCURRENCE 5- OCCUR CLAIMS MADE AGGREGATE s i DEDUCTIBLE i RETENTION i i wmwmam E CONPIPMATON AND STATU- OTH- EUPLOVERS'UASLTIY TNE 2012W6419 0128/2013 01/282014 El.EACH ACCIDENT It 100,00 NPREWPA7RCMLU 4®CU E.L.DISEASE-EA DAPLOYEE S 100,001) ME w wYls�ds11Sb~ E-q-0*EASE-POUCYUWr i 5000DD OTTER DEBCRPTICN OF OWMATIOE91 LOCATIDTTE T VEMCLm/EIICLJJ m"ADDED Br shoo RiIDI16RT I SPIMAL FROVISKUM CERTIFICATE HOLDER CANCELLATION SHOULDANY OFTHEABOIIO OLSCRRIEDPOUCIES SE CAYCUUM MUMETIIE®IR^Mom DATE THEREOF,THE IS30Y4 IMMARR TILL ENDEAVOR TO MALL 30 DAYS frYRTTTBI NOTKE TO THE CER w=TE HOLDER TIAMED TO THE LEFT.BUY FmjRIE TO OO s0 SNALIL IMPOSE NO OBLIGATION OR WYILTY OF ANY RIND UPON THE INSURITR,ITS AGENTS OR R�i�fTATNEs. AYTTIOIIaiD ACORD 25 f20010111 ®ACORD CORPORATION 1968 COMMONWEALT H.OF 111ASSACFIUS • E77S SHEET MEIII lail T R • AS q MgSTER UNESTERS ISSUES THE gEOVE LICENSE TOTE <; r►AV. � .,ICA RR' CIRO. III 18 GREEN' LN ASSO` NET - 5203 II128/Iy . 291233 .COMMONWEALTH OF MASSACHUSETTS e e • ••• a :•• •e • ' :SHEET METAL WORKERS AS,A BUSINESS ISSUES THE ABOVE LICENSE-f0: D.nVI'D J CARREIRO II'I CARREI'RO & CARLSON MECHCAL CT ' m ?8 FREETOWN STREET -,-LAKEVILLE MA 02717'-081..6,.:.. 190 01/11/15 306246- The Commonwealth of Massachusetts Department of1ndusbgd Accidents Office of,nvestigadoirs -600 tWashington Street Boston,M4 02111 UV. www.mass.gov/dia ' Workers' Compensation IusurA .ce Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leebly Name(Busmesslorgauiz�ion/3ndivi :.�'. 22�1�0 �• C'y4(Z�.�'pYl City/state/Zip: E .FreaTo"Jn h,.4 ez O Phone.#: T 7 q-q A O —S(Q � Are you an employer? Check the appropriate bow Type of project(reqnired) 1.[�I am a employer with 4. ❑ I an a general cmaftactor and I . employees (fall and/or part 1irne1.*. _ have hired�e shb=cgab-contractors6. s ❑New ccrostrnrfinn 2.❑ I am a sole proprietor orpariner- hsted on the-attached.sheet 7. F]Remodeling ship and have no employees These sub-contractors have 8. ❑Damo1•ition working for me irr my caparity, employees-and have workers' [No workers' comp.msnrance comp.msrnance., ' 9. ❑Bmi ding addition required,] 5. []'We area carpoiatinn and*its ME]Electrical repass or additions 3.❑ I am a homeowner doing aIl.work officers have exercised&3ij11.[]Plumbing repairs or additions myself [No workers' camp. - H&of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4), and we have no 13.❑ Other employees. [No worlmrs' comp.insurance re#wed] *Any appkant that checks box#1 amst also fiII out the section bclow showing tbes workers'compeusaiion poficY infiumai iaL t Elameownas who snbaut tis affidavit infeaimg they arc doing all work and ibex hie outside canizaetors osist subuat a new afadavit in icaiiag such. *Conttacum that ob b this box most attached au addiffuaal sheet showing the name of ffib sub-canhacton and shb-wbcfoa•armt those eut<ties have cmplayees• U the sub-cunt i a bave empiny=S,&rY mustpravide their wm3F='camp.poHcynnmber. I am an employer that isproviding workers'compensation insurance for my employees Below is thepoAq and job site information. Insurance CQmpanyName: F,y?,_frl PAON Policy#or Self-ins.Lic.#k o[© � W era Expirati Date: g Job Site Address: 644-0, C�'iState,�ZiF;�Ll2Tall s' N�1�`'�ik't N1� Atf-a rh a copy of the workers' compensation policy-declaration page'(showi g the policy n=ber and expiration date). Faflure.to.secmE coverage as requiredmcler Section 25A ofMGL c. 152 can lead to the imposition of coal penalties of'a fim up to$1,500.00 and/or one-year mnpi3 orrm= ,as well as civil penalties in the firm of a STOP WORK ORDER and a fine of up to$250.00 a day against the vio Be advised the a copy of this ststemerit may be fin warded to the Office of lay ons of the jDI&48r f verificatm I do hereby certify and penalties of pm7ury that the information provided above is true and correct Side: Date _ Phone# S� Official use only. Do not write,in this area,tb be completed by csly or-town of iciaL City or Town: PermitUrnnse# Issuing Aztthority(circle one): ; -1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector b. Other Contact Person: Phone#: Town of Barnstable Regulatory Services t Aa R1VC'AAile' s PR+ea Thomas F.Geiler,Director Building Division Tom Perry,Building Commissioner 200 Man Street;Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax 508-790-6230 Property Owner Must Complete and Siam This Section If Using A.Builder ,as Owner of the subject property hereby authorize r 1 !fl to act on m b m all matters relative to work authorized by this building permit (Address of Job) Pool fences and alarms are the responsibility of the applicant. Pools are not-to be filled.before fence is'installed and pools are not to be Zudou.ntil all final inspections ar4�petiforrmed ' d accepted. Owner pplicant Print Name Print Name Date FMh 3:0 Q' WI�2PER.MISSIOIQPOOIS •. ' ( _ �71 E Town of-Barnstable Regulatory Services �nxxsresr.E, : Thomas F.Geiler,Director . nsess 1639. •�� Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.mai.us Office: 508-862-403 8 FaX 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street - village "HOMEOWNER': name home phone# work phone# CURRENT MAILING ADDRESS: 'N Its. city/town state zip code � The current exemption for"homeowners"was extended to include owner-occupied dwellings of six ants or less and to allow homeowners to engage an individual for hire who does�pos e�a liceuseproyided t}iat'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#h8m` owner. Such "homeowner"shall submit to the Building Official on a foffi acceptable=o 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 ;m„m inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner v Approval of Building Official "�'- ' IA Note: Three-family dwellings containing 35,000 cubic flee4r larger will be required to comply with the State Building Code Section 127,0 Construction Control HOMEOWNER'S EXEMPTION ,14 Sti The Code states that "Any homeowner�performrng`wdrk for which a l uildmg pemrit is required shaA 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 responsrbtlities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15).This lack of awareness often msults in serious problems,particularly; when the homeowner hires unlicensed persons. In this case,our Board carmot proceed against the unlicensed person as it would with a licensed` 1 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 rssponsrbilities 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 far use in your community. y • Q:fonTs:homeexempt: .. t l + ..1 r r � ;I ' ti r • r .. Assessors map and lot number ......... ......................... of THE Sewage Permit number ..... :.. 5 .............. d�Q�R�♦�. ' / 1 > �1 �o,ass s. TODL • House number .................... .......................... roes ..................... p 1639. { 1 MIR p�9 r I TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ...................... 640p,.�.......:................................................... TYPEOF CONSTRUCTION ..................................... .....................:............................................................. ............ 'T.... ..........19..8-4 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ................................................... ..�!�1.... . f1�v.. .................. ..P.�Y............f.......................................... ............. Proposed Use Qev Zoning District .....................!.!.. ...................:.....................Fire District ..................�-f!/......... ., �� %. ,, D S ............ . . ....... ✓!1... �6SS Name of Owner ....... A .N..........�!/.....G.1�............................Address ....�...y...�1.Al.�V....T.... w. Name of Builder '�°h"V. �' "S''viE�oS...................Address y0 y � afn.7f.!lY.�l ........................... l..Y.. T...... Name of Architect �6!s' .............................Address 'V '9 Number of Rooms ........................... .......................................Foundation ............ 4uiifcJ . Exlerior C�fUA�/„S�c!/N9�ES.�......aPaq"/ 0-'4i'�0,1A)Roofing. ................ �5�!�!✓q lc,/.......................................... ................... .................. Floors ............................ ........................................ Interior .............................................. Heating ....:.:......:...F�E�T 2/G.....:...:.` :::........"..:::.. ..Plurr'ib ng ..::....:`.....:..:...:l..... :....�...:....:....... ...... ... .... Fireplace ...................................f/oNf.'.................................Approximate. Cost .................. Definitive Plan Approved by Planning Board -------------------_-----------19________. Area .....F ..............2...... Diagram of Lot and Building with Dimensions Fee .........../J.o'............. ................... SUBJECT TO APPROVAL OF BOARD OF HEALTH `RMO i 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. T r Name ...... ....`.:........ ..... Construction Supervisor's License . A _ SHIELDS, JOHN T. A=27-112 27037 1-2 Story No .... ............ Permit for ...1................................. Single Family Dwelling ............................................................................... Lot 85, 141 S Lane Location ....................................P ..................... Marston Mills ............................................................................... Owner ..John. T. SI-delds ......... .........t............................................ Type of Construction. ....Frame.......................... ................................................................................ Plot ............................. Lot ................................. Permit Granted ...October 1,.....................................19 84 Date of Inspection ....................................19 Date Completed ......................................19 � | Setwage Permit number OITL TOWN OF BARNST REGULATIONS BUILDING", INSPECTOR TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Diagram of Lot and Building with Dimensions Do- SUBJECT TO APPROVAL OF BOARD OF HEALTH � | OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS | ! hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. ^' Nome ....... .~(,— ................... � . Construction Supervisor's License .................................... ' m SHIELDS, JOHN T. 27037 A- Story No ................. Permit for .................................... ......Sing1e..FaffrLjjy..J)We.1-1-ing....................... .Location .....Wt..85......141,9Pur.Jaru........... .................... ..I W.Jz............................ Owner ..... ............................ Type of Construction ..Frame............................ ................................................................................ Plot ............................ Lot ................................ Permit Granted ......CCt0ber..1...............19 84 Date of Inspection/0:7-M. -I-4.1- ..................19 Date Completed ....../...............................119 +w . SPU 2 t_ = 109.�4 — L oT 85 — +I i a� fO V rl d.. 45 J 55 +I LoT go B4- 1GI CE,IeT/F/�� pL OT /�L AEI P p-E P A P-E D Fop-- 40CATiow: SARQsTAE>L-E , MASS. JAck SHo�T scAQA-,- : 1" \ * 91E54 EAST BAY BUI LD1 IQG �EEFE.E'�.c/cE: BEING L.oT 85 ^' PL. B}t. Zr]Z , PG.9� M WAI�EBY ESTATES" SHO N/.-/ O.t/ Tf-//S PL Fi.V IS L OC Fi TE a OA/ T/IC- (F"C>U vn .Qs --SA.IO WA-1 HE.e6o" /•ava ARNE yry\`• 1 i.i. ma`s i GUA!A r26348 W cvn Caere en9ineer�r�9 Oct t -- A-- LolTE a.4 aaArt L.OiA./a scievcYoe MURPHY AND MURPHY TELEPHONE AREA CODE 617 HENRY L. MURPHY, JR. COUNSELLORS AT LAW 775-3116 J. DOUGLAS MURPHY 243 SOUTH STREET NOTARY PUBLIC LOCK DRAWER JEFFERY JOHNSON HYANNIS, MASSACHUSETTS 02601 T. DAVID HOUGHTON September 27, 1984 OUR FILE No. 6215B Joseph DaLuz Building, Inspector !'own of Barnstable Town Hall Main Street Hyannis, MA .02601 Re: Lot 85, P1an. Book 272, Page 92 Spurr Lane Marstons Mills, MA Dear Mr. DaLuz: John R. Short , Jr. requested that I provide you with some information with regard to the above captioned lot. A copy of the plan is enclosed. John T. Shields is the present record title holder to the premises. He acquired title from East. Bay Building Co. , Inc . which had acquired title from Frances May Baskin by virture of a deed recorded July 23, 1984. 'Mrs. Baskin .at one time- held title to 13 lots by virtue of 3 deeds. By deed recorded in Book 2085, Page 32 on August 16 , 1974 she acquired Lot 84. By deed recorded in Book 2085, Page 33 on August 16, 1974 she 'ac= quired Lots- 61 , 92-; 69 and 83•.. By deed recorded in -Book 2177„ Page .39 on May 2., 1975 she acquired Lots '39, 41 , 49, 59, 67, 71 , 73 and 85. I am told by the Planning Board that the zoning in this area of Marstons Mills changed at Town Meeting November 4, 1978. . The plan_ had bee app- roved June 5, 1973 and recorded July 3, 1973. The pertinent lots to. this discussion are Lots 83, 84 and 85. Pursuant to Chapter 40A 96 paragraph 4 the five year period of protection begins to run on the later of January 1 , 1976 or the effective date of the change. Mrs . Baskin conveyed the middle lot 84 on October 24, 1983 by deed re- corded in Book 3904, Page 208. On april 6 , 1984 a deed to Lot 83 was recorded in Book 4061 , Page 62. I am told there exists a building permit for said Lot 83 and that construction is in progress. s September 27, 1984. Joseph DaLuz ` Page 2 I trust this information will be helpful in making your determination. . - Sincerely, J e7rJo hnson ` JJ:cs Enclosure S J FROM �- TOWNS OF BARNSTABLE BUILDING DEPARTMENT W. FRANCO TAHTEM367 MAIN STREET HYANNIS, MA 02WI ' a►-v►v•+was..j+�w..•.y+r�•a♦r,PwY�RV1m'V y� Town Clerk Phone, 775-1120 ' �I A.l N�em bra�rR r?.i esMA4a.i! � r� SUBJECT: 7„ FOLD HERE I DATE - January 28, 1985 MESSAGE Work has been cmpleted under Pdrm t #27037 (John T. Shields), .. ,7{np'Wr,r R'Y x-vpe., 4�„rri waa 9.{,e m.aN:y�v9�Yai.75! �•aaay.vr' �a a'?m»a+ww-3u`�.e sMsawwa-m•rrM.•w,••1v,e-s.'E. �tti Please release Bond. + .�`pF.•'.aC.4"R'.Yµq.�i{s,�4Y'Flwa/.b.M?^YW✓4Myi,y N'tt OM°'.�t•1�9�4�'R . SIGNED .. DATE a .. i•...a ✓.�- REPLY SIGNED I N87•RMI RECIPIENT: RETAIN WHITE COPY,RETURN PINK COPY a PRINTED IN U.S.A. SENDER: SNAP OUT YELLOW COPY ONLY.SEND WHITE AND PINK COPIES WITH CARBON INTACT. o , TOWN OF BARNSTABLE Permit No. ---27037---------------- Building Inspector I sauac Cash __--_-- OCCUPANCY PERMIT Bond Issued to J'phn T. Shields.. Address int- 85- 141-Spur Lane. M.arsthmg Mill Wiring Inspector �G ,��� Inspection date Plumbing Inspector Inspection date Gas Inspector r ., v Inspection date xEngineering Department ' Inspection date S J Board of Health /C f n-,c.G.Pi ' Inspection date � a L THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE.MASSACHUSETTS STATE BUILDING CODE. I Building Inspector I t N C% 4! IV N j. • 24 C, coz 10, e. 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