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Home My WebLink About0264 TREE TOP CIRCLE �� ,' ,� a , ,n a � a . �� -�„ n. , - �. y, ° h �_� _ ,_. , .. � � � � ,G � - � - � � _ '.> - r., - ,, � - .. � -..". .. .n .. _ r. .. "' r o,,, - ., J, , c o �. _ _ .r.. �. ,. , ,. n � � � ... - - .. ., � ,i R c r... - � .� ,. �. ,r- n }� � .. �. � � - .,. ., � � ,. - �. - ��. .y � - .. . > ... ,., �" ` � - � a � � . . y_.a6 . � � n _ .. - .. -� _ .. - � t� � �-�, ". �a � e � �.. �. ,. �'rQ. - H�� ... ,r ... , ,. . � � - , _ � �, y.. �,- ,�, �. .. _ � � e .. � _ i _ � - ,. .. a� . . � �. � � .. .. � �- a � .. � ., .. - � , - -� ,.. ., , �.r�,/a ,. � - .. n .. - a ,. j ��.r`".'-` ,�,^ . .-. � r� �^..., ,. `"'��.: c �_ c .��H n.- ,.��.,../�} � •. y.l `� mks' L� (�i.. � � � r C�� a)�" Town of Barnstable Building Department Brian Florence, CBO Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Pre-application for Business Certificate Date Map 1, Parcel O Applicant Information Applicants Name Applicants Address 71QO/�J Tcle Address V05//70 01 a Q/Ica, er / - Telephone Numb 0)- Listed ❑ Unlisted [- Business Information New Business? -------------------------------------- Yes No Business is a registered corporation? -------------------------- Yes If yes Name of Corporation Does business operate under the registered corporate name? Yes No Is the business a sole proprietorship or home occupation? --------- Yes No If yes then a Home Occupation Registration is required-See Building Division Staff Name of Business Business Address D!/ li e ,O /�/�� ze / ��/(�/15 /%� 00C�y(� Type of Business Building Conigussilo er Office Use Only Conditions Building Commissioner Date Clerk Office Use Only Town of Barnstable THE r Building Department '"R''STABIA AS& Mass. Brian Florence,CBO �At i639 p�� Building Commissioner ED MA'S 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 7/22/2020 Susan A Dean 264 Treetop Circle Marston Mills, MA 02648 Dear Ms. Dean, Re: 264 Treetop Circle We are in receipt of your request for a pre-application business certificate. In the town ordinances it does not allow a home occupation as a matter of right in the zoning district of R.F. Under 240-46 (C) a home occupation in this district requires you obtain relief from the i zoning board (special permit). The first step in this process is obtaining approval with a Site Plan-Review letter. Maggie Flynn is the Site Plan Review Coordinator(508-862-4679) and she can assist you with this if you wish to proceed:I am returning your payment that accompanied your pre-application for a business certificate. Once you have obtained your special permit.we can process your request. Sin re , Sa ly Shea ; Town of Barnstable Assistant Zoning Admin/Lead Permit Tech. 508-862-4031 signs/signrequ&app revised: 9/22/17 Cape Save Inc. 7-1) Huntington Avenue South Yarmouth, MA 02664 Tel: 508-398-0398 Fag: 508-398-0399 8/10/16 e� C) Thomas Perry CBO Town of Barnstable p �' Building Division 200 Main St. Hyannis,MA 02601 r RE: Insulation Permit 16-1980 Dear Mr. Perry i This affidavit is to certify that all work completed for 264 Tree Top Circle,Marstons Mills has been inspected by a third party Certified Building Performance Institute(BPI)Inspector. All work performed meets or exceeds Federal and State Requirements. Sincerely, William McCloskey !Y' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION BUILDING DEPT Map Parcel 0 Application # Health Division JUL 12. 2016 Date Issued Conservation Division TOWN OF BARNSTABLE Application Fe Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address T"e C i rc >L Village ��himrkj I << U Owner S 00'V1 t S+f 8 Q� Address 5 4.�'fY�ej Telephone Permit(Request -3 S 0 D Gi 1` .Cjaj e, aG I G 19 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District a Flood Plain Groundwater Overlay Project Valuation ` l Construction Type I lot 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: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ I Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes KNo If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name cv C_ Telephone Number S'm a ?92 Address License # ( (� T fa ov � l urrr►�►`� ��(�0�19 0�� Home Improvement Contractor# j Email Worker's Compensation # 55 q ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE ` � V FOR OFFICIAL USE ONLY `APPLICATION # ' DATE ISSUED MAP/ PARCEL NO. l h ADDRESS VILLAGE OWNER . {{ DATE OF INSPECTION: ' FOUNDATION ' FRAME `T INSULATION 7 FIREPLACE „s ELECTRICAL: ROUGH FINAL rr PLUMBING: ROUGH FINAL GAS: 'ROUGH FINAL FINAL BUILDING : DATE'CLOSED"OUT. s ASSOCIATION PLAN NO. r Town of Barnstable. Relg*t y Services Vicharrd"'V:SMH Directoor �$�Il��1'U'iSIUIQ Tom*�-P(err,M 734.0ding_(:ir oner •1r111tQ !aMki"OLEA 0201 Office: 50$462.4038 fax SQL_?90-6230 Prope Owner Mutt Copp er anti:Sign This.-Secoon Y; S CO TF C—S-FPIELLR ' hereby auffiorize. Y .to am:an b in Z ratters x+k ive:to work authorized by tI&bugding percalt`appkation for. Aw 7ke e C ( s . _ '"fool feces and a]aus .:ib ° spans ' paiicaools are.novt&be:fled or` fifiied befbie fea66.1s i��and- -final inspe,ceons a :g oimaed-�nl:accepked. f ofinatvie:of:hppliaant Print Print N Dare i �I Q.FORMS:OWNWERAgSMMIOOLs ............._..._.._.__..._.._.. .... CORLJ DATE(MMIDDIYYY`) A CC> CERTIFICATE OF LIABILITY INSURANCE 4/12/2016 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 pollcyQes)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 endorsemen s. ONTACT E Risk Strategies Company PRODUCER CAM Risk Strategies Company ac E : (781)986-4400 FAX No (781)963-4420 15 Pacella Park Drive E-MADDR�:randolphcld®risk-strategies.com Suite 240 INSURER(S)AFFORDING COVERAGE NAICS Randolph MA 02368 INSURERA:Selective Ins. of America INSURED INsuRERBAllmerica Financial Alliance Ins Cc 10212 Cape Save, Inc INSURERC:Star Insurance Cc 7 D Huntington Ave INSURER D: INSURER E: South Yarmouth MA 02664 INSURERF: COVERAGES CERTIFICATE NUMBER:CL1641211375 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS. rA TYPE OF INSURANCE POLICY NUMBER MMJDDNYYYJ O ICY EFF MPOMI I E P LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGETUWERrO CLAIMSMADE �OCCUR PREMISES Ea occurrence $ 100,000 X 91994480 10/16/2015 10/16/2016 MmEXP Myoneperson) $ 10,000 PERSONAL 8 ADV INJURY $ 1,000,000 GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICYCaT LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED eaWdent) $ 1,000,000 B ANY AUTO BODILY INJURY(Per person) $ TOSM� X �OEDULED AWBA46796600 11/6/2015 11/6/2016 BODILY INJURY(Per e0cident) $ NON-OVMIED PROPERTY DAMAGE $ X HIREDAUTOS X AUTOS Pereccident X UMBRELLA UAB X OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAS CLAIMS-MADE AGGREGATE $ 1,000,000 DED I X I RETENTIONS NIL 1 181994480 10/16/2016 10/16/2016 $ WORKERS COMPENSATION Officers Included for - X PER OTH- AND EMPLOYERS'UABRITY YIN STATUTE ER ANY PROPRIETORIPARTNERIEXECUTIVE coverage E.L.EACH ACCIDENT $ 500,000 OFFIOFFICER/MEMBEREXCLUDED? NIA C a (Mandatory In NH) WC085540700 4/9/2016 4/9/2017 E.L.DISEASE-EA EMPLOYEE $ 500,000 It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500 000 I DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached If more space Is required) National Grid Corporate Services LLC d/b/a National Grid, Action Inc, Colonial Gas Company and NStar Electric are all included as Additional Insureds with respects to the General Liability coverage of named insured as required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Housing Assistance Corporation THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Cape Light Compact ACCORDANCE WITH THE POLICY PROVISIONS. Barnstable County 460 west Main street AUTHORIZED REPRESENTATIVE Hyannis, Lea 02601 Michael Christian/CLC O 1088-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025(201401) The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 h www massgov/dia IvVorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Apulicant Information Please Print Legibly Name (Business/Organization/Individual):Cape Save Inc Address:7-D Huntington Avenue City/State/Zip:South Yarmouth, MA 02664 Phone#:508-398-0398 Are you an employer?Check the appropriate box: Type of project(required): 1.2 I am a employer with 15 employees(full and/or part-time).* 7. New construction 2. I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling , any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.a I am a homeowner doing all work myself.[No workers'comp.insurance required.]f 4.❑I am a homeowner and will be hiringcontractors to conduct all work on m 10[]Building addition y property. I will ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance. 6.❑we are a.corporation and its officers have exercised their right of exemption per MGL c. 14.❑✓ Other Insulation 152,§1(4),and we have no employees.[No workers'comp.insurance required.] •Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. ;Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. if the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Star Insurance Co. Policy#or Self-ins.Lic#: WC085540700 Expiration Date: 4/9/2017 Job Site Address: 264 Tree Top Circle City/State/zip:Marstons Mills Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.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 th pains and penalties of perjury that the information provided above is true and correct Si attire: Date: 1/1 Phone#:508-398-0398 Official use only. Do not write in this area,to be completed by city or town official City or Town; PermitlLicense# 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#: Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Cont`r`actor Registration Registration: 171380 Type: Corporation s ,• Expiration: 3/14/2018 Tr# 419291 CAPE SAVE INC. WILLIAM McCLUSKEY 7-D HUNTINGTON AVENUE SOUTH-YARMOUTH, MA 02664 i, Update Address and return card.Mark reason for change. Address Q Renewal ❑ Employment Lost Card SCA 1 0 20M-05/11 ffairuer Bu iness Regulation � License or registration valid for individul use only Oftice of Consumer Affairs&BusinessRegulatioo g Y ^' HOME IMPROVEMENT CONTRACTOR before the expiration date If found return to: La. Registration:. -1713g0 Type: Office of Consumer Affairs and Business Regulation a - 10 Park Plaza-Suite 5170 Expiration:;—3l=1412018 Corporation _ = Boston,MA 02116 CAPE SAVE INC. WILLIAM McCLUSKEY 7-D HUNTINGTON AVENUE= ' .�s•�3 `,�.,. SOUTH YARMOUTH,MA`02664? Undersecretary Not valid AiA signature Massachusetts -Department of Public Safety Board of Building Regulations and Standards 1�1111111 U1111'111 Jll rl C'111111�JIICIIL li_V '.�a License: CSSL402776 .;,::1T:ti WILLIAM J MC CCU Y- 37 NAUSET ROAD elf West Yarmouth MA r - J..L.+_4�1 ....)r m+ Expiration Commissioner 06/2812017 �1HE Shed TOWN OF BARNSTABLE Permit * BARNSTABIE, MASS. s6 �ArE p 39�- a Permit Number: Application Ref: 201501943 20150850 Issue Date: 04/24/15 Applicant: COOK, RUTH A Proposed Use: Accessory Structure Permit Type: SHEDS 200 SQ FT &UNDER Permit Fee $ 35.00 Location 264 TREE TOP CIRCLE Map Parcel 126025 Town MARSTONS MILLS Zoning District RF Contractor PROPERTY OWNER Remarks INSTALL A 1OX12 SHED Owner: COOK, RUTH A Address: 264 TREE TOP CIRCLE MARSTONS MILLS, MA 02648 Issued By: RM POST THIS CARD SO THAT IS VISIBLE FROM THE STREET Town of Barnstable �TME'�ti Regulatory Services Richard V. Scali,Director 9="R'`STA8M ems. Building Division $ 1639. RFD MA'1�' Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable-ma.us Office: 508-862-4038 Fax: 508-790-6230 PERMIT# FEE: $35.00 SEED REGISTRATION W RESIDENTIAL ONLY 200 square feet or less Rh-S 1-70"p C!JgCLE f9 R 2 7��/i Is 0,/j-4,�) Location of shed(address) Village l�o J;D •- qc-�,O- -7353 Property owner's name Telephone number Z,2z 6 as- Size of Shed Map/Parcel# Signature Date Hyannis Main Street Waterfront Historic District? vJ Old King's Highway Historic District Commission jurisdiction? =a If over 120 square feet,you must file with Old King's Highway ran 0- 9 Conservation Commission(signature,is,regnired) � /�l/ Sign off hours for Conservation 8_00-9:30&3 30-4.30 PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMaSSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-she&eg REV:040914 Town of Barnstable Geographic Information System April 13,2015 , 126033 Noe- *� #228 150043 #233 150054 #275 rNEF TOP CFe vO �Af 126023 #240 126024 #250 126025 #264 15OD41 #276 150042 7F 25 126021 #280 126020 #266 126019 #254 150040 # 42 150039 0 9230 0 22 Feet DISCLAIMERS:This map is for planning purposes only. It is not adequate for legal Map:126 Parcel:025 EJ boundary determination or regulatory interpretation. Enlargements beyond a scale of Selected Parcel t'=100'may not meet established map accuracy standards. The parcel lines on this map Owner:COOK,RUTH A Total Assessed Value:$205700 are only graphic representations of Assessor's tax parcels. They are not true property Co-owner: Acreage:0.46 acres Abutters _ tflt E boundaries and do not represent accurate relationships to physical features on the map Location:264 TREE TOP CIRCLE such as building locations. Buffer f�� Par A;ermit#1 ' JConservation Office(4th floor)(8:30- 9:30 30/1:00-`2:00) `Dhte Issued 7—1;2--3 Board of Health(3rd floor)(8:15 -9:30/1:00-4:45) C� '' �1 ? Fee S� r BE Engineering Dept.(3rd floor) House# (c `1 SF•pTIC��5�E �T WCE s r W INSTALLED I TH 19 NVIRONM� TOWN RE 3Proreet TOWN OF BARNSTABLE Building Permit Application ddress Village Owner Address Telephone i a 9 - Permit Request / First Floor square feet Second Floor square feet Estimated Project Cost $ ;20?!!7>,. pp Zoning District (�,�� Flood Plain Water Protection Lot Size Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use Proposed Use Construction Type Commercial Residential Dwelling Type: Single Family ✓ Two Family Multi-Family Age of Existing Structure Basement Type: Finished Historic House a Unfinished Old King's Highway 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 1 Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# 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 DATE BUILDING PERM DENIED FOR THE FOLLOWING REASON(S) PP .' FOR OFFICIAL USE ONLY . f P RMIT NO. D TE ISSUED €i f If AP/PARCEL NO. e AljDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION ' FRAME- INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH f FINAL GAS: `ROUGH FINAL FINAL BUILDIN&' DATE CLOSED OUT ASSOCIATION PLAN NO. • tt +""' The Cunrnionwealth of Massachusetts Department of Industrial Accidents s O!1lceollayi;�dgatlo�s ��\ :I�.: - •a' 6001f mititigum Street �..) %; t+ Bunton,Alas. 02111 Workers' Compensation Insurance.AlTdavit Inc-nt on- city 11*�9 �-- � 3 am a homeowner performing all work myself. 1 am a sole proprietor and have no one working in any capacity ❑ l am an emplover providing workers' compensation for my employees working on this job. com24}snmc• - asidrets• -' - }•• nhone#• insurance co nolicv# r. ..r.. r+ ::w�-..-:.:�.......: ..!.�..wr...y.+�,�!►..•�R:7J0'' ��.•_ar,.r�.•-.�,.__._. _ .—r.�_� - _ . 1 am a sole proprietor,general contractor, or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: comp•tn}•name- address, come phone#: insurnncc co •• nolicv# • ' ' • . �.-:—:- - . w.•�-•a.•ss :+! •'T�'^,�!,',yF.�'r';..rsa�res�r -+ter l�e �v-*ram .e�3*s!.+r'_'" �f com am•name! address: - c*tV• phone#: insur•)nce coIIOIiCT# _ :Atiach'additianafsheet if tiee�•�- - •r ^:_++'" .:,"ar"a rr�``c'` ="`r" :" ' %+s+.L Failure to secure coverage as required under Section 2SA of 111GL 152 can lead to the imposition of criminal penalties of a fine up to S1.500.00 and/or une rears'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage vitrification. I do rebt•certifj• ndcr site pa its and Wallies f-perjuq•that the infornroiion pnn7ded abo s true and conrc� ienaturc ate Print name o S o:�fj � • v G Phone# 0 Icial use only do not write in this area to be completed by city or town otlieial ein or town: permit/license# rlBuilding Department C31.1censing Board ' 0 check if immediate response is required OSeleetmen's OMce C311e2lth Department contact person: phone#;. rnOther (mued-3M5 P)A) .Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide %vorkers' compensation for their employees. As quoted from the "law", 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 :::gal entity, or any two or more o the fore�_oing 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 occupam of tite 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 1'52 section 25 also states that every state.or local licensing agency shall withhold the issuance or renewai 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.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 hav been presented to the contracting authority. ,.�w..�r.�.t+��..��Rw. �.+�•�.�w .y:.. •a : � �y,,,`��-�i:CY';n: 'v"){.:ar� . .. •-••- Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying-company names. address and phone numbers as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affida+it. 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. 77 s77,,,f•.,,m,,.rn. ,..o-..e�!+.r.?��r.: _ - •�.,"; .:i:,,,'_ :�j�. X.A°':7:;:y.�' Ld:�..'!+r"-:.� � ,.. _,isyt,:ac7,«.a+�c,"v_5:.;'�< � ._. - .•.• w •• ::.. =�Y'.0.. .r7,•iw�°..a •fN. :3 ••r.'Ai78!• �•.. ws Yi• Cite or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. 'The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investi_ations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. r..w..�..+.�re..�....n...�.—�!.!!f..s+ .. .. _ _ .Y:;: .... ':.. fin.;.�; ..... - .G:e�...�:.:.:�-w..�_.- ..:y�:r :;;:F.;•.::.. F...tea.... -- '.y�•r•,,,1: ~i •LYr.,�;. .•+,A•a'•'=4"•';:�:nuv�•� �:�•;rn.. :y•-yy..:- The Department's address, telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street — Boston,Ma. 02111 ♦ fax#: (617) 727-7749 phone#: (617) 7274900 ext. 406, 409 or 375 The Town of Barnstable KAM Department of Health Safety and Environmental Services Building Division s 367 Main Stznct,Hyannis MA 02601 Office: 508-790-6227 Ralph Cros= Fare 508 775-33" Building Commis` For office use only Permit no. Date AFI+MAVIT HOME 5WROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alteratimm renovation,repair;modernization,conversion, improvement,.removal, deraolition. or construction of an addition to any pre-adsting owner occupied building containing at least one but not more than four dwelling units or to stlucoues which are adjacent to such residence or building be done by registered contractors,with certain=Cpdons, along with other requiremeats. Type of Work: � Est.Cost Address of Work: Owner.Name: Date of Permit Application: "T /9 r I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under SI,000 g not owneroccupied Owner ping cmm Pit Notice is hereby green that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH VNREGI3'iIED CONTRACTORS FOR APPLICABLE HOME WROVEMENr WORK DO NOT HAVE ACCESS TO TIE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. Date Contractor name Registration No. OR y n,,a Owner's name \ 29 +� / ;�\ X78.5 �, ,� �'/� �• 81.1 X 78 3 . x 2 / - \ \ a I oil, 13 _1 5.4 } .20 CD . ZVI r . 37 — — ' } 72.2 -�'I i 4 , •,1�,.�•�,c;r1� I +i>�K.i>l� r`\.1��.1��.. �� yet :. 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N\i�•� rT'::«K'�.Assembly Part Part Quantity Check Key No. Number Description in Carton List 1 3719 Door Handle Brace 2 — 2 '5986 Rear Wall Angle 2 3 6264 Horizontal Door Brace 4 .4 9355 Vertical Door Brace 2 5 6403 Door Track Splice 1 6 8.995 Wall Panel 4 . a 7 9364 Wall Panel 4 . '8 9769 Comer Panel 4 9 7483 Roof Panel 4 10 7723 Rear Wall Channel 2 11 9360 Right Door 1 12 9361 Left Door 1 1.3 6000 Right Gable. 2 14 6001 Left Gable 2 15 8740 Side Wall Angle 4 16 8742 Ridge Cap 2 17 8743 . Side Roof Trim 4 . 18 8744 Right Roof Beam 4 19 8745 Left Roof Beam 4 20 8747 Side Wall Channel 4 21 8934 Ramp 1 22 8936 Rear Floor Frame 2 23 8945 Side Floor Frame 4 - 24 6635 Gable Brace 2 25 . 7484 Right Roof Panel 2 26 7485 Left Roof Panel 2 27 9365 Front Wall Channel 2 28 9366 Door Track 2 29 9367 Front Floor Frame 2 30 9368 Door Jamb 2 31 9372 Front Wall Panel 2 12 7