HomeMy WebLinkAbout0010 VIOLA LANE V
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• TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map- Parcel
Parcel• LPL "Application b
Health Division Date Issued
Conservation Division Applicatio' n.1ft,�
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH Preservation/Hyannis
Project Street Address f1' (l try .J? 4? ' /nS7bNs f�i//S. Mq 02648
Village E,
Owner04!?'�' *'�_Adaress S'AAIE As 46,966
Telephone 4m 3/B8
Permit Request _ _ _801,4 N&,(,J bAek, �'��3
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation 19040 Construction Type
Lot Size Grandfathered: U Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family Ur/ Two Family ❑ Multi-Family (# units)
Age of Existing Structure afsK_C Historic House: ❑Yes YNo On Old King's Highway: ❑Yes l0
'-, o
Basement Type: 4`Full ❑ Crawl ❑Walkout ❑ Other
Basement Finished Area(sq.ft.) Basement Unfinished Area(sgAr'I =< o
Number of Baths: Full: existing new Half: existing = new
Number of Bedrooms: existing _new '
�o
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_
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 .SCof A 101W AEe= Telephone Number (S-W) 77/-OZ`f/
Address 2N7 5_M4U4-44 Alt &kd_ License # CS 78000
� i✓ ',6yj& 94- Home Improvement Contractor# UZ41
Worker's Compensation # !!/IA
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
lgral
SIGNATURE DATE P
FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED -
MAP/PARCEL NO.' -
ADDRESS - VILLAGE
OWNER "•� � �� '-" �;, . �'«��
DATE OF INSPECTION: ! i
r FOUNDATION t��Santos be u
FRAME +T
r t
INSULATION
FIREPLACE I
ELECTRICAL: ROUGH r•-' FINAL J
PLUMBING: ROUGH FINAL • !% '
GAS: ROUGH FINAL
v
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO. . :_-��
r
r Town. of B arwtable
TVAERegulatory Services
« �}tSTAUL�
Thomas F. Geiler,Director.
MAs-C '
i6s9: ,`0� Building Division
Thomas Perry, CBO,Building Commissioner
200 MaijaStreet, Hy�s,MA- 02601
www.town.barnst-ble.wa.us
r,
Fzx: .508-790-6230
'Office( 508-862-4038
PLAN REVIEW
/� _VOw —DOct .
Owner: to ;.
Map/Parcel: _ 7
Project Address /o �o
The following ifen)s were noted on reviewing:
L ttf �9 in-T T VO�sT �o �
Reviewed by:
Date:
r
,yam The CotnjHonwealth of Massachusetts
\ Department of Industrial Accident'
Office of Investigations'
600 FYashington Street
.BOSLort) AU4 02111
www.in ass.govldia
Workers' Compensation 7ngarance davit: Builders/Contractors/El ectricians/PIumbers
Applicant Informatioli Please Print Legibly
Name (BusinossJOrgani�tion/individual): ,fL'.O� f!' Qy� �/L '
Address: a47 Shgo4_
City/State/Zip: dsw4uml . MiF 0 1- Phone.#:
Arc you an employer? Check the appropriate boz: Type of roject(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6 New construction
employees (full and/or paztaimc).* have hired the slit-contractors
2.[)I am a'solc proprietor or partner-
listed on the attached sheet 7. ❑Remodeling
ship and have no employees These sub-contractors have g• Demolition
employees and bane workers'
working for me in any capacity• 9. ❑Building addition
[No workers'.comp.•insuraacc comp. insurance.t
5. [f We area corporation and its ME] Electrical repairs or additions-
required.]
3,❑•I am a homeowner doingall work officers bavc exercised their I LE]Plumbing repairs or additions
myself. [No workers' conv. right of exemption per MGL 1�.0 Roof repairs
c, 152, §1(4), and we have no
in „ ccregliired]t 13.❑ Other cran .
employees. [No workers'
comp,insurance required_]
*Any applicant that'cheeka box#1 must also fill OUt the Section below showing their workm' compens4on policy information.
t l-lomeovmcrC who submit this affidavit indicating they art doing all work and that hire outside contrsetors must submit a new affidavit indicating such.
h2ontractors tint check this box must attached an additional sheet showing the name of the sub-contrattrns and state whether or not those cntitirs have
employees, Lf the sub-contractors have cmployccs,they murt providb their workers'comp.policy number.
lam art employer Chad isprovidbtgworkers'compensation insurancefor my employees. BeCoty is the policy andjob site
info rm atlom
Insurance Company Name:
Policy# or SeLf-ins. Lic. #: Expiration Date.
fob Site A-ddress: City/Statc/Zip:
Attach a copy of the workers' compensation policy declaration page (sbovQingthe policy number and expiration date).
Failure to secure covcrago as required under Section 25A of MGL c. 152 can lead to-the imposition of criminal penalties of a
find tip to 51,500.00 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 tbat a copy of this statcmcdt may be forwarded to the Office of
Investigations of the L4 for insurance coverage verification.
l do hereby certi der the pains•and pen es 'fperjury Ilt.at the information provided above is true and correct.
Si afore: Date: —
Phone # (.710/ 77 ORf
Official use only. Do riot write in LhLr area, to be comlpieted by c'ily or town offrciaL
City or Topwa: Pernit/License#
Issuing Autbority(circle one):
1. Board of Health 2, )3uilding Department 3, City/Town Clerk 4. Electrical Inspector 5. Plumbinglnspector
6. Other
r•_�R__, n__ �. Phone tl:
InforTnation and Inst .ue ionstheir
Massachusetts Gcncral Laws chapter 152 requires all employers to provide woz of aDotb p nder any contract l�o,
Pursuant to this statute, an employee is defined as "...every person in the service of
express or implied, oral or written-"
An ern. Loyer i9 defined as "an individual, pa.rtncrship, association, corporation or Other legal entity, or any ta,000�znorc
the le al re rescntativcs of a deceased employer,
of the foregoing engaged in a joint enterprise, and including g p e to ecs. However the
zoceiver or trusted of an individual,p�cmhip, association or other legal entity, employing nxp Y
than three apartments and who resides therein, or the occupant of the
owner of a dwelling house bang not more air work an
dwelling house of another who employs persons to do o r I-op
`aius mplo
ee Hof such truction oyrnent be deemed to beaan employer-"
or on the gro�mds or building appurtena t thereto shall.
MGL chapter 152, §25C(6) also states that ,every state or local licensing agency shall aTthhold the issuance or
reraewo'of a license or permit to operate a business or to con.frace uAdith theslin he insurancecommonwealth
f o redy
appllcautwho has notprodueed•acceptable cvi.dence of compl subdiyiSiDUS
Additionally,MGL ohaptcr 152, §25C(7) states Neither eomnmok until ptw�blctcvidcnorncc of omplianY of its ee with the insura-nce
enter•into any contract for the performance of publi w
f this chapter have been presented to thc.contracting authority.
requirements o
Applicants
Please fill out the workers' compensation a fidavit completely,by checking the boxes that apply to your situation and, if
nccessazy, supply sub-contractors)namc(s), address(cs) and phone numbs along oycessother than the
insurance. Limited Liability Companics'(LLC) or Limited Liability Partnerships ( )
with no mombers or partners, arc notrcquized to carry workers' compeosation insurance• If an LLC or LLP does havc
employees, a policy is required- Bc advised that this affidavit may be submitted to the Dcpart<zicnt of Industrial
Accidents for cozzfirmatiozx of insurance coverage. Also be sure to sign and date the affldaviti The a$davat should
bo returned to the city or town that the'application for.the permit or license'is o ��quui Department of
zcd to obtain a worker
Industrial Accidents. Should you have any questions regarding the law or if y ecf
compensation policy,Plcasc call the Department at the)a ber listed below. Sclf-insured componies sbuld enter their
self insuranco liccasc number on the appropria.tr;Line-
City or ToWP Officials
Please be sure that the affidavit iS'complete and printed legibly. The Department has pz0 i c g the c bo 0.a
of kho affidavit for you to fill out in the event the Office of lnvcstigatiow has to contact y regarding pp
Please be sure to fill in the permit/hccnse numblit
er which will be used as a reference number. In addition, an applicant
j that must submit multiple permit/hccnse applications in any nt
given year, aced only submit onp affidavit indicating cc coz
policy information(if pecessary) and under'Job Site Address tho applicant should write"all locations r rided to the
town)."A cbpy of the affidavit that has been Officially stamped or marked by the city or town may P
applicant as pzoof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be lilted out each
year.'Whero a home owner or citizen is obtaining a liccnsc or permit not related fo any business or commercial venture
(i c, said p6rsou is NOT required to complete this affidavit.'
a dog license or'pcimit to bum leaves etc.)
Tha Office of Lnvcstigatioris would hke to thank you in advance for your cooperation and should you have any questions,
please do not hesitato tti give us a call.
The Department's address, tcicphone•and fax number:
Thtt Commonw al.th ofMa&whtl t tts
D trpartme4t of zndust60 Accid=ts
Offict of Sxivesidptl.aus
600 Washington Street
Poston, MA 02111
Ti,-]; # 617-727-49-0.0 ext 406 Qr 1-$'77-MASSAFE
Fax# 617-727-7749
Revised 11-22-06 yryyw.mas.S..gov/dia
�ofIHEr° Town of Barnstable
Regulatory Services
r
BARN srA13LE. ' Thomas F. Geiler, Director.
v .MA
�°rFocb`� Building Division
Tom ferry, Building Commissioner
200 Main Street, Ryannis, MA 02601
w�vw.toivn.ba-rnsta ble.mn.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Cb-Mplete 'an.d Sign This Section
If UsirIg A Builder
as Owner of the subject propetty
hereby authorize to act on my behalf,
in all matters relative to work authorized by this building permit application for:
/l��9.(•a (,e�.����s�e-,�.s vet 'r�s •
(Address of Job)
,jlJllU
Signature of Owner Date
Print Name
If Property Owner is applying for permit please complete the IIomeo'9Mcts License
Exemption Form on th•e reverse side.
•
` 'own of Barnstable
Of'(NE
Regul torY.Servzce5
• Thomas F. Geiler, Director
t BARNSTAB[.S,
�Q MASS. Building Division
L7 sd7p. �m .
°rFo hwt` Tom Perry,Building Comtrilssionel' .
200 Main Street, Hyannis, MA 02601
njy)y.town.bariistable.ma.us
Fax: 508-790-6230-
Office: 508-862-4038
z H0A4EOWt\`1 R LICENSE EXEMPTION
Plense Print
DATE:
JO$LOCATION: street village
number
"HOMEOWNER": home phone u work phone#
name
CURRENT MAILING ADDRESS:
state zip code
city/town
ts
or les.s
The current exemption for"homers"was extended to include owner-occupied
d dwellings
ided that tha owner act and
as
to allow homeowners to engage an individual for hire who does not toss a ,
supervisor. AEI.7T�ITION OF HOAIEOVYNER
de, on which there is, or is intended
Person(s) who owns a parcel of land ozi'which acides or cessory s to �tosuch use nd or farm structures. to
be, a one or two-family dwelling, attached or detached structures ccsory
er. Such
person who constructs more than one la Official on.a in a ar periodrm shall not to the Building Official,that he/she shall be
"homeowner shall submit to the B g
responsible for all such work performed under the building pert, (Section 109,1.1)
onsibility for compliance with the State Building Code and other
The undersigned "homeowner" assumes resp
applicable codes, bylaws, rules.and regulations. .
The undersigned "homeowmer"certifies that he/she understands theTown
to 0 comply said procble edures and
minimurn inspection procedures and requirements and that he/sh P Y
requirements,
Signature of Homeowner
Approval of Building Official .
Note; Three family dwellings containing 35,000 cubic feet or larger will be required.to comply with the
State Building Code Section 127.0 Construction Control. ..
FIOMEOWNER'S BX) MPTION
The Code states that: -Any homeowner performingpwork for which a building permit r- required agels ac exempt ffor hire lorom the rdotsu h
of this section(Section lo9.),I -Licensing of consuvetion Su•crvisors ' rovided that if the horncowncr cng g p ()
work, thal such Homco)vncr shall act as supervisor,"
Many homeowners nhoConsWetio Shensupc i Arc
unaware
Section that
2.15)they
arc
lack of assuming the
awarcnesooftcnlretsu)tsf in scrioussprobIwo,particularly
Rules &Regulations for Liccnsr g
when the homeowner hires unliccnscd persons. in this cast,our Board cannot proceed against the unlicensed person as it would N�i[h a licensed
Supervisor. The homeoveneracting as Supervisor is ultimatclyresponsible.
un
To ensure that Lthat by he understands the reis fully aware sponsibilities liticcr s of a responsibilities,
the last page of thiscs require, issue slue is atform currently'used by
that the homeowner certify
ar viral tmvns. You may care t amend and adopt such a fom✓certification for use in your community.
Ma'ssachusctts- Department of Public Safety ��6
Board of Building Regulations and Standards , ,> ;
Nw Construction.Supervisor License
License: CS 78000
1 .
Restricted to:,•00 �.��.y =u f, �, .�'` x � �f��,�y.•s'-
SCOTT H DUILTER*;.} �w ��( i - •, Y,,:•° ry ��"� .;�rs.�, 5
PO BOX 727
9! e,trpU
.- 8Z #, .w+�
W HYANNISPORT, MA 026723697,
�iyZE? ua F
5 3�)JI t a' 3�{. lf0�n,J�s
IN
Expiration: 2/3/2012 -
4
as
Commissioner Tr#: 21477 �n/��rGua /� f ttrok21 `rf� J;r' rw k
- f
Massachusetts- Department of Public Safety
Board of Building Regulations and Standards
YJ Construction.Supervisor License '
License: CS 78000 ,- f `•'y -
Restricted to: 00 6- r ,�. :<<f�i off` '��,��+k �'�,,�;,-� •
SCOTT H QUIETER r x I^ 04
Uw- A.. �
f tr I'
PO BOX 727
W HYANNISPORT, MA 02672
r ` �+ '`. ♦ yvpn\•k-� .l�/... �� � �ltyyy,i�S � 'S� 1
Expiration: 2/3/2012
�
Commistiiuncr
-- _ Tr#: 21477
;M vC•.�tE�cJa
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HIC Registration Complaints Page I of I
The Official Website of the Office of Consumer Affairs&Business Regulation(OCABR)
Consumer Affairs-and Business Regulation
Home"Consumer"Housing Information ` Home Improvement Contractor Program>
---............--...................................—.......................................................................... .........................................— ..... .....................
H|C Registration Complaints
Registration N /3269/
Name uCoTT0mLTsn
City,State,Zip csmTsnv|LLs.MA,m0z
Expiration Date 3u3u01/
8mmm Con*m
No complaints found for this registrant.
You can also view arbitration and Guaranty Fund histo .
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HANDRAIL
36 GUARD RAIL STAIRS
< 4" OPENINGS x Pj-. ,p
HOUSE WALL
FLASHING
2-1 /2" LAG BOLTS
WITH WASHERS
FLOOR JOISTS
1 /2„ X 5„
. 1
CONCRETE ANCHOR
�10 -- SIMPSON ADJUSTABLE
POST BASE CONNECTOR
10" DIAMETER
48" DEEP FROST FOOTINGS
SIDE ELEVATION
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Town of Barnstable *Permit ^(�
Expires 6 months from issue date
X-PRESS PEF MITkegulatory Services Fee . b
Thomas F.Geiler,Director
DEC 1 2 2007 Building Division
TOWN OF BARNSTAf.'erry,CBO, Building Commissioner O
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4.038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIIDENTIAL ONLY
( Not Valid without Red X-Press Imprint
Map/parcel Number —1 d 0c /ot
Property Address U/o/4 _e
EaResidential Value of Work 7l Q00 Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address
Contractor's Name f h e .Ne m e De grT 4 t ji an e Telephone Number' Q(c;�l-
Home Improvement Contractor License#(if applicable) f a 8
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance /
Check one:
❑ I ain a sole proprietor
❑ I am the Homeowner
I have Worker's Compensation Insurance
Insurance Company Name N '
e W, /'I g in 02.s k I P e •)�a 5, G o-
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
Re-roof(stripping old shingles) All construction debris will be taken to t is c�� � 5"to e 1
04 �47�
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
❑'Replacement Windows/doors/sliders. U-Value (maximum.44)
*Where required: issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement.Contractors License is required.
SIGNATURE: ���,,cp &444 6.
Q:Forms:expmhg
Revise061306
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f,'11f J1
The C61j_lm6111 ed11h,,°6f4assnchi se �i++h
Depar(t'i'en1 of lnilirst al Accidents l �
Office of Investigations;,, ;;+ :j�'�il
600 Kashington Street
Boston, MA 02111 I
w wivw.niass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
ApOlicant Information Please Print Legibly
Name (Business/Organization L
/Individua0: 1 )
Address: 5 s 4 Ce 5 e
<t r ,
City/State/Zip: �r u H 4� .6A 30337 Phone#: SO O ' 6 5 '� a
' r
Are you an employer? Check the appropriate box: Type of project(required):
1. I am a employer with_L__— 4. ❑ I am a general contractor and I 6. ❑ New construction
employees(full and/or part-time). -have hired the sub-contractors
listed on the attached sheet. 7. ❑ Remodeling
2.❑ I am a sole proprietor or partner- These sub-contractors have
ship and have no employees 8. ❑ Demolition
employees and have workers'
working for me in any capacity. y ❑ Building addition
[No workers' comp. insurance comp. a corporation
oral
required.]
S. � We are a corporation and its l0.❑Electrical repairs or additions
3.El I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12t@ Roof repairs
insurance d.re uire t c. 152,§1(4), and we have no
required.)
employees. [No workers' 13.❑Other
comp. insurance required.]
*Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must-attached an additional sheet showing the name of the subcontractors and state whether or not those entities have. .
employees. If the subcontractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: NeL" rr a wt P s�1 r „+/vl 5• `✓io12 —
Policy#or Self-ins. Lic. #: q a / 4Z G Expiration Date: 3
Job Site Address: /o C I n & C t4► City/State/Zip o/sA, P t/,
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
Investi ations of the DIA for insurance covers a verification.
I do hereby certify under the pains and Pena ies of perjury that the information provided above is true and correct.
Date: '� �2 —
Signature: G
Phone#
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authoritti (circle one):
1.Board of Health 2. Building Department 3.rity/ToWn Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
j jI it i
l nand lirstz=uctions , .r ;
�InforM* atio ,i
' ;t ;r �� �,. f,t �e�'j, ICI �; I���� , I�• �t�,l : ;
jtassac Jill setts (:rene.ral LAWS chapter 152 requires all enipl0j6s io W6,7idi com
W(ifkcrs pensation
Pursuant to this statute, an emplo},ee is defined as "...every person in the service of another under any contract of hire,+tIl i
express of implied, oral or wTitten.' }
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership, association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or _
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any �+
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance,, _
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s) along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the pernut/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 iiu (city or
town)."A copy of the affidavit that has-been officially stamped or marked by the city or town may be provided to the
applicant'as'proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 11-22-06 N,,,"-Nv,mass.gov/dia
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PRODUCER
MARSH USA INC THIS CEATIPICATE'18 ISSUED A�`A MATTER OR INFORMATION'ONLY AND'CONFER$
NO RIGHTS UPON THE CERTIPICATE HOLDER OTHER THAN THOSE PROVIDED IN THE
FAX(212)948-trequestQmarsh.cam i, POLICY.THIS CERTIFICAT$GOES NOT AMEND,@X7EN0 OR ALTfiR THE COVERAGE r''
i FAX(212)946-0902 •AFFORDED @Y THE POLICIES OESCRI@EO HERfiIN.:.'_'. •[:...' 1"i": I
3475 PIEDMONT ROAD,SUITE 1200
ATLANTA,GA 30305 COMPANIES AFFORDING COVERAGE
COMPANY
00492-THD-IPU8A-07-08' IPUSA A STEADFAST INSURANCE COMPANY
INSURED
COMPANY
HOME DEPOT USA,INC. 8.. ZURICH AMERICAN INSURANCE COMPANY
2455 PACES FERRY ROAD NW
BUILDING C-8 COMPANY --
ATLANTA.GA 30339
C .•AMERICAN HOME ASSURANCE COMPANY
:..COMPANY
D NEW HAMPSHIRE INS COMPANY
�F411E1� GES �'`"°. ..R : �fi t _ ''�'a�`•��[I. �.� ►S�R2 �...��Yn. �� OEM
",J"�.���.a�; r+ _
— -_' k1ai dif[E'aIE�o tI ref of ' rep ss a Certl tad{ pt c::�ogte THIS.IS TO CERTIFY THAT POLIO ES OF:INSURANCE DESCRIBED HEREIN-HAVE•BEEN'LS$uE0•.TO TIiE,INSUREO NAMEQ HEREIN.FOR?}IE'POUCY'PERIOD',WOICATED
NOTWITFISTANDING ANY REQUIREMENT;TERM OR CONDITION OP ANY CONTRACTOR OTHER OOCUMEIVT WITH RESPECT TO WHICH THE CERTIFICATE MAY l3E 1S5UE0 OR MAY
PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL.THE TERMS,CONDITIONS AND EXCLUSIONS OF SUCH POLICIES.AGGREGATE.
LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. - ,' •
C0' TYP@ OF INSURANCfi POLICY EFFfiCflVE POLICY EXPIRATION LTR POLICY NUMBER'..
DAT@'(MMIDDIYY) GATE(MMIDDIYY). LIMITS
i q , GENERAL LIABILITY . . IPR 3757 608-02 .' 03/01*107 .. 03/01/08
X COMMERCIAL GENERALUABIL GENER 4.000,000
ITY LIMITS OF POLICY ARE EXCESS' AL AGGREGATE $
PRODUCTS-COMP/OPAGG $ 4,000*000
CLAIMS MADE a OCCUR 'OF SIR:$1,006,000 PER OCC' .:' PERSONAL&AOV INJURY $ 4,000,000
OWNER'S&CONTRACTOR'S PROT EACH OCCURRENCE $ 4,000,000
------------
FIRE DAMAGE tiny One fire $ 1,000,000
B AUTOMOBILE UABIUTY MED EXP An One arson $ EXCLUDED
BAP 2938863-04. 03/01/07 03/01/08 COMBINED SINGLE LIMY $ 1,000,000
X ANY AUTO
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) $•
HIRED AUTOS B000.Y INJURY
NON40WNEDAUTOS (Peraeddeno $
X ELF-INSURED AUTO
HYSICAL DAMAGE PROPERTY DAMAGE $
GARAGE LIABILITY
AUTO ONLY-EA ACCIDENT $"
ANYAUTO OTHER THAN AUTO ONLY •O�' b'K rA
EACHACCIOENT $ .
A EXCESS LIABILITY AGGREGATE $
IPR 3757 608-02 63/01/07 03/01/08 EACH OCCURRENCE $ 5;000,000
X UMBRELLA FORM AGGREGATE $ 5.000,000
OTHER THAN UMBRELLA FORM $
C WORKER COMPENSATION AND 2921209(CA) "
EMPLOYERS�uea1TY 03/01/07 0310 108 X A OT
1 TORY LIMITS ER
E 2921210(FL) 03/01/07 03/01/08 ' EL EACH AcaoeNr $ : 1,000 000
F. 7HEPROPRIETOR/ X INCL 2921211(AZ,ID,MD,VA) 03/01/07 03/01/08 ELDISEASE•PoucruMlT $ 1,000;000'
D PARTNER§IEXECUTNE
OFFICERS ARE: EXCL2921208(AOS) .03/01/07 03/61/08 EL DISEASE-EACH EMPLOYEE $ 1;000,000
C OTHER' 2921213(QSQ 03/01/07 03/01/08
.E . WORKERS'COMPENSATION 2921212(KY,MO,NY,WI) 03/01/07 03/01108
G TEXAS EMPLOYERS. TNS-C44642086(TX) 03/01/07 03/01/08 , EACH OCCURENCE
EXCESS LIABILITY 25,000.000
DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESISPECIAL ITEMS SIR 2 000 000
rt $,CA..
L.a:2+ii:.$4�15'H�rSY..SI�...�5�•. 'Le.�.' is`�: 'S '' i L.a�'Y�•"6c'5., x {.ts GLIKTIO�.a�•r24tfbf,
rc't ;S� '*,.i.t'•'.'s�s'3"'�. xF'..".,,,` ''• ,,'�.�.;. c's�. ..3`.;.�a•.,s ' e'r,,
sst�..�:TW�ii�� '*a
�s
SHOULD ANY Of THE POLICIES DES
CAMEO HEREIN BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,
THE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO MAIL- '10 DAYS WRITTEN NOTICE TO THE
FOR EVIDENCE ONLY- - CERTIFICATE HOLDER NAMED HEREIN,BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
1
F LIABILITY OF ANY KIND UPON THE IN AFFORDING COVERAGE,ITS AGENTS OR REPRESENTATIVES,OR THE '
y ISSUER Of THIS CERTIFICATE.
x I
si ct�ttlx II'��j KF R)lpt (��`f IJI t I ) l N r (L1�, MARSH USA INC.
M r�
ary BY Rad8S2t3WSILI
M2 - VALID AS OF j02128/07 ,. :.
• '.. ,......- �' -: .', I, _ ' GATE(MMIOOMrI'.-�..
COMPANIES AFFORDING COVERAGE
PRODUCER
MARSH USA.INC.`. p . COMPANY
homedepot.cedrequest@marsh.coM E ILLINOIS NATIONAL INSURANCE COMPANY
FAX(212)948-0902
3475 PIEDMONT ROAD,SUITE 1200
ATLANTA,GA 30305 'COMPANY
F ... : NATIONAL UNION FIRE INS CO '
100492-THD-IPUSA-07-08 IPUSA
INSURED COMPANY +
HOME DEPOT USA;INC. G ILLINOIS UNION INSURANCE CO
2455 PACES FERRY ROAD NW
BUILDING,C-8.
ATLANTA,GA 30339 COMPANY
HIN
Sow,^
CERIFFICAT,EHOWER � ��t '' 'g'•
. FO VI NCE ONLY
{..
• MASH USA INC
� � t
li I Mary Radaazewski ?rrj "
�N`.
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✓rae �omym� °�
Board of'Building Regulations and Standards ; License or registration valid for individul use only
HOME IM, ROVEMENT CONTRACTOR
before the expiration date.,If found,return to:
,.R .� Board of Building. and Standards
Registi'dtioh: 126893 One Ashburton Place Rm 1301
Expiration =8/312008 Boston,Ma.02108
p i,lemen t Card 1
P�
THE Home Depot t= e1C
DAME
3200 COBB GALLRt1N.Y#20
Not valid:with ut signature
Atlantic,GA 30339 Administrator _. __.--•_-- .._...-_.:............._-._....._.......
r
Danya Mahot 7743230034 p. 6
HOME E14PROVFXWNT CONTRACT
Sold,Furnished and Installed by:
Branch Name: 4 Date: �� THD At-Home Services,Inc
d/b/a The Home Depot At-Home Service,
345A Greenwood Street,Worcester,MA 01607
Branch Number: Job#: � Toll Free(800)657-5182; Fax: 508-756-2859
Federal ID#75-2698460 ME Lic#C 02439 Rl Cont.Lie#1642-1
/'/' Lic#565522; Home Improvement Contractor Rcg.#12689:
Installation Address: AQ W/ tkI C( G
City State Zip
Last 4 Digits of Driver's
Purchase Lic.#&Ex o/Yr: Work Phone: Rome Phone:
Wo
Home Address-
(If different from Installation Address) City State Zip
E-mail Address(to receive updates and promotions from The Home Depot):
Project Information: I/We/You ("Purchaser"), the owners of the property located at the above installation address, offer tc
contract with THD At-Home Services, Inc. (" a Dept" to furnish,deliver and arrange for the installation of all materials
as described on the attached Spec Sheet# incorporated herein by reference and made apart hereof.
Home Depot reserves the right to cancel this contract if,upon re-inspection of the job,Home Depot determines that it
cannot perform its obligations due to a structural problem with the home, pricing errors or because work required to
complete the job was not included in the Spec Sheet or Contract.
DEPOSIT PAYMENT OPTIONS
(Subject to fund verification and/or credit approval.)
CONTRACT AMOUNT $ 1. Check*,Cashiers Check or US Postal Service Money Order
`y— (Made payable to The Home Depot).
`' tLESS DEPOSIT S
2. Credit Card"and/or other payment options-Circle One Below
BALANCE DUE Visa MasterCard Discover American Express
ON COMPLETION $tt Zw
me Depot Home Improvement Loan he Home Depot Cred�i Cry
tMinimm 25%of Contract Amount due upon ccount : ❑Existing Account (HIL&HDCC ONLY)
f�tecu on of this contract Available Credit:$ (HIL&HDCC ONLY)
Indicate Payment Method For Acct#: __ p.D
BALANCE DUE ON COMPLETION:
• Name as it appears on card: / Oaci"r
—By my/our signature below,I/We agree to allow Home Depot to
j char e a e refe coda redit car or the deposit indicated.
-When you provide a check as payment,you authorize us either l v
to use information from your check to make a one-time electronic aidholder's Signature Date
fund transfer from your account or to process the payment as a
check transaction.When we use information from your check to HIL or HDCC Authorization Codes
make an electronic fund transfer, funds may be withdrawn from
your account as soon as the payment is received,and you will not Deposit Final Pa ent
receive your check back.
Purchaser agrees that, immediately upon completion of the work,Purchaser will execute a Completion Certificate and pay any
balance due. Purchaser also agrees to be jointly and severally obligated and liable hereunder.
Entire Agreement: This agreement and its attachments, including any financing agreement, contain the complete agreement
between the patties and can not be amended or modified unless in writing in a separate agreement signed by both parties.
NOTICE TO PURCHASER
Do not sign this contract before you read it. You are entitled to a completely filled-in copy of the contract at the time
you sign. Keep it to protect your rights. Do not sign a Completion Certificate before this project is complete. Law
nr4%hl%1#Q hnmP rnnutr rnnevarfnm frnm rnnnncfinn nr arepnfinn is rmmnlPtinir C'PrtiliratP cinnPel by the nwner nrinr to
Danya Mahot 7743230034 p. 7
BALANCE DUE / G Visa MasterCard Discover American Express
ON COMPLETION $ C/CO r :eee,
e me Depot Home Improvement Loan a Home Depot CrodS C�
fiMiaimum 25%of Contract Amount due upon Account [IExisting Account (HIL&HDCC ONLY)
ecnuUon of this Contract Available Credit:$ Odv (HIL&HDCC ONLY)
Indicate Payment Method For Acct# xp.Darm_
BALANCE DUE ON COMPLETION: l
Name as it appears on card:_ Gt!.i
—By my/our signature below,I/We agree to allow Home Depot to
j char e a e ref ced redit car or the deposit indicated.
*When you provide a check as payment,you authorize us either U
to use information from your check to make a one-time electronic dholder's Signature Date
fund transfer from your account or to process the payment as a
check transaction.When we use information from your check to
make an electronic fund transfer, funds may be withdrawn from HIL or HDCC Authorization Codes
your account as soon as the payment is received,and you will not Deposit Final Pa ment
receive your check back. # '1 #
Purchaser agrees that,immediately upon completion of the work,Purchaser will execute a Completion Certificate and pay any
balance due. Purchaser also agrees to be jointly and severally obligated and liable hereunder.
Entire Agreement: This'agreement and its attachments, including any financing agreement, contain the complete agreement
between the parties and can not be amended or modified unless in writing in a separate agreement signed by both parties.
NOTICE TO PURCHASER
Do not sign this contract before you read it. You are entitled to a completely filled-in copy of the contract at the time
you sign. Keep it to protect your rights. Do not sign a Completion Certificate before this project is complete. Law
prohibits home repair contractors from requesting or accepting a Completion Certificate signed by the owner prior to
the actual completion of the work to be performed under the contract.
You may cancel this transaction any time prior to midnight of the third business day after the date of this contract. Sec
Notice of Cancellation for an explanation of this right. There will be a service charge equal to 10% of the contract
amount if job is cancelled by Purchaser AFTER the third business day,but BEFORE materials are ordered.There will
be a service charge equal to 25%of the contract amount if job is cancelled by Purchaser AFTER materials are ordered.
BY MY/OUR SIGNATURE BELOW,I/WE UNDERSTAND THAT THE AGREEMENT MAY BE SUBJECT TO REVIEW
OF MY/OUR CREDIT HISTORY AND T/WE AUTHORIZE HOME DEPOT TO VERIFY AND REVIEW MY/OUR
CREDIT RECORD WITH AN INDEPENDENT CREDIT REPORTING AGENCY AND RELEASE THEM FROM ALL
LIABILITY INCURRED FROM INADVERTENT OMI ONS ORE S.
BY MY/OUR SIGNATURE BELOW, IIWE AG TO BED BY THE TERMS OF THIS CONTRACT. I/WE
ACKNOWLEDGE RECEIPT OF A COPY O 1S CO OCT AND TWO COMPLETED COPIES OF THE NOTICE
OF CANCELLATION. �7 C
SUBMITTED BY: Date:
resultant
ACCEPTED BY: Date:
Pure
Date: X
PurolmiRr
NOTICE: ADDITIONAL TERMS AND CONDITIONS ARE STATED ON THE REVERSE SIDE
AND ARE PART OF THIS CONTRACT
9-21-07 rev 4-2-07 C-SC White-Branch File Yellow-Customer Pink-Sales Consultant
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map V Parcel 0(40 `'v Application# o` 4
Health Division �h
Conservation Division Permit#
Tax Collector Date Issued �1
Treasurer Application Fee
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board '
Historic-OKH Preservation/Hyannis
Project Street Address 0 V 1t9LA- LA&
Village���,-s, j,s M IL 4,
Owner At'd ZL,>,n,:SA C,'�) c "k) Address A- p,,e
Telephone -3 t g 8
Pe mit Ret quest 12- Po i tj N
--�; rQ
Square feet: 1st floor:existing proposed 2nd floor:existing proposed =1 Total new-�
Zoning District Flood Plain Groundwater Overlay
.. cn
�Projecf_Valuafion- d 600 Construction Type , T,
Lot Size�?jT?10 54 1 Grandfathered: ❑Yes ❑No If yes, attach supporting do umentation.
Dwelling Type: Single Family k' Two Family ❑ Multi-Family(#units)
Age of Existing Structure C ' Historic House: ❑Yes ANo On Old King's Highway: ❑Yes I(No
Basement Type: Pull ❑Crawl ❑Walkout ❑Other
Basement Finished Area(sq.ft.) 3 Basement Unfinished Area(sq.ft) 3z,
Number of Baths: Full:existing new Half:existing new
Number of Bedrooms: existing_ new 2q /— �✓
In ��'IJCw�e✓V� �'_
Total Room Count(not including baths):existing new First Floor Room Count `�'"
Heat Type and Fuel: kGas ❑Oil ❑Electric ❑Other
Central Air: ❑Yes EAo Fireplaces: Existing New Existing wood/coal stove: ❑Yes 4 No
Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size
Attached garage:❑existing ❑new size Shed:A existing ❑new size Other:
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes IkNo If yes, site plan review#
Current Use Proposed Use
BUILDER INFORMATION Ct
Name ����(y ven s Cj � 1 Telephone Number � �� /�p
Address�/[L( rd 1 .e License#
A&� -5 41 Id- OZ(Tp Home Improvement Contractor#
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
2 ru
SIGNATURE DATE 4, rz, In -
I
FOR OFFICIAL USE ONLY
PERMIT NO.
DATE ISSUED
MAP/PARCEL NO.
ADDRESS - VIL'LAGE
OWNER
DATE OF INSPECTION:
FOUNDATION ��St7II��OS
^F
FRAME
INSULATIONe I bW ®�
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL r,
GAS: ROUGH FINAL
FINAL BUILDING -
,J
DATE CLOSED OUT
1 ASSOCIATION PLANNO.
f
The Commonwealth ofMassachusetts -
.Department of Industrial Accidents
Office of Investigations .
"•_ a 600 Washington Street
° Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Iiasurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): �� � ¢ �� C16 r L)a J
Address: /m V 10,(.:A--l_4-rrg-
City/State/Zip: jQRfS-(p,c� 0?lkPhone.#:
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
have hired the sub-contractors 6 ❑New construction .
employees (full and/or.part-time). '
2.❑ I am a•sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship mdhave no employees These sub-contractors have g. ❑Demolition
working for me in•any capacity. employees and have workers'
[No workers' comp.insurance comp, insurance.
$ - 9. ®Building addition
required.] 5. ❑ 'We are a corporation and its 10-❑Electrical repairs or additions
3.CKI am a homeowner doing ill 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 13:[�Other�c�r
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 affidat*it 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 sbowing the name of the'sub-contractors and state whether ornot those entities have
employees. If the subcontractors have employees,they must provide their workers'comp,policy number.
Iam an employer that is providing workers'compensation insurance for my employees. Below is.the policy andjob site
information.
Insurance Company Frame:
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.jo secure coverage as required under Section 25A of MGI,c. 152 can lead to the imposition of criminal penalties of a
fine tip to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK OR=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_ofthe DIA-for insurance coverage verification.
I.do hereby cep' der the pains andpen alties ofperjury that the information provided above is true and.correct.
Siena'
i atar / Date: C
Phone#: Z/.�
Off-cial use only. Do not write in this area, to be completed by city or town offrciaL
City or Town: Permit/License#
Issuing Authority(circle one):
-1..B.oard of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
b. Other
Contact Person: Phone#:
Information and Instr°ucti®ns .
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, !
express or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a-deceased employer, or the
=eceiyP.T or=1 e-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 pernut to*operate a business or to construct buildings in the commonwealth for any
applicantwho 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-contractor(s)name(s), address(es)and phone number(s) along with their certificate(s)of
insurance. Limited Liability Companies'(LLC) or Limited Liability Partnerships(LLP)with no employees other.than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or.license is being requested,not the Department of
Industrial Accidents., Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate-line.
City or Town Officials.
Please.be sure that the affidavit is complete'and primed 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 ventute
(i.e. a dog license or permit to burn leaves-etc.) said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions
please do not hesitate to give us a call.
The Depaztment's address,telephone-and fax number:-
b` Commonwealth of Massachusetts
Department of In ustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-7-27-490.0 ext 406 or 1-M-MASSAFE
Fax# 617-727-7749
Revised 11-22-06
www-.Mass.gov/dia
� E � 1 v TT Al vl 1JaX AJLO LCL1Jly
w
Regulatory Services
sr rE. Thomas F.Geiler,Director
��'°,�r► ;,,'��� Building Division
Tom.Perry,Building Commissioner.
200 Main Street, Hyannis,MA 02601
www.town.b arnstabl e.ma.us
ice. 508-862-403 8 Fax: 508-790-6230
Permit no.
Date
AFFMAVn
HOME IMTROVEMENT CONTRACTOR LAW
-SUPPLEMENT TO PERMIT APPLICATION
MGL a 142Arequires that the"reconstruction, alterations,renovation,repair,modernization, conversion,
improvement,removal, demolition,or construction of an addition to any pre-existing owner-occupied
building containing at least one but not more than four dwelling units.or to structures which'are adjacent to
such residence or building be done by registered contractors,with certain es�ceptions, along wi, other
requirements.
Type of Work: Y-� Estimated Cost
Address of Work: lit2 Sb'a 47 r A14C. 6,;,/ MirGl S
Owner's Name: R
Date of Application
I hereby certify that:
Registration is not required for the following reason(s):
[]Work excluded by law
[•Job Under$1,000
[]Building not owner-occupied
[ weer pulling own permit
Notice is hereby given that:
0,*ERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME WROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c..142A.
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the agent of the owner:
Date' Contractor Signature Registration No.
Date Owner's Signature
Q wpfil es.forms:hom eafri d av
Rev: 060606
RESIDENTIAL:
SHEDS -POOLS—DECKS-OPEN PORCHES-GAZEBOS
FEE VALUE WORKSHEET
APPLICATION FEE: $50.00
BUILDING PERMIT FEES:
ACCESSORY STRUCTURES >120 sq.ft.(Sbeds,gazebos, etc.)
>120 sf-500 sf $35.00 $
>500 sf-750 sf 50.00 $
>750 sf.-1000 sf 75.00 $
>1000 sf- 1500 sf 100.00. $
>1500 of USE NEE BUILDING PERMIT APPLICATION
DECKS x$30.00= $
(Number) -
TO RC_ H�ES .. ,_x$30.00= S.
(Number)
GRptJND SWIMMING POOL S60.00 $
ABOYE GROUND SWIlVIlYIING POOL $25.00 $
gELOCATION/MOVING $150.00 $
(plus above fee if applicable)
• .. - REKNIT FEE • $ . .
Q:forms:dkcost
pXV:063004
x
Town of Barnstable
y�P Regulatory Services
BARNSrABLE, : Thomas F.Geiler,Director
9 MASS.
039• Building Division
TEv �p 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: '' 0
JOB LOCATION: /D V[01/_A G/¢NC G s�•v ��l rlS
number /� `street ! village
"HOMEOWNER": Phi/ I 4, e C,GgcA 1"e' 5_09 `�aLB 31 d S
name home phone# work phone#
CURRENT MAILING ADDRESS: Vd?)6C4 ZA!71�
city/town�s /t/CQe zip code
The current exemption for"homeowners"was extended to include wAmer-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
"homemmer"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
spection procedures and requirements and that he/she will comply Arith said procedures and
equireme s.
ignature of omeo�mer
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the
State Building Code Section 127.0 Construction Control. .
HOMEOWNER'S EXEMPTION
The.Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions
of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such
work,that such Homeowner.shall act as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,
Rules&Regulations for Licensing Construction'Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly .
when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed
Supervisor. The homeowner acting as Supervisor is ultimately responsible.
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,
that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by
several towns. You may care t amend and adopt such a form/certification for use in your community.
Q:fotms:homeexempt
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The Town of Barnstable
9 � Department of Health Safety and Environmental Services
E159. Building Division
367 Main Street,Hyannis MA 02601
Office: 508-862-4038 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
SHED REGISTRATION
Location of shed(address) Village
Property owner's name Telephone number
i0 x z 0 Z2 00 6
Size of Shed Map/Parcel#
D
y
Signature Cam' Date
Hyannis Main Street Waterfront Historic District.
Old King's Highway Historic District Commission jurisdiction?. QG oq/00 0!:5P�—
U
Conservation Commission(signature required)
PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE
COMMISSIONS,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•shedreg
/ STANDARD LEGEND
/ 3 O NOTE:not all symbols will appear an a map
/ J) GOLF COURSE FAIRWAY
EDGE OF DECIDUOUS TREES
^� EDGE OF BRUSH
ORCHARD OR NURSERY
Tr—T` ' EDGE OF CONIFEROUS TREES
MARSH AREA
\/ ---• • •---- EDGE OF WATER
ODIRT ROAD
` I DRIVEWAY
�PARKING LOT
J �PAVED ROAD
DRAINAGE DITCH
— — — — PATH/TRAIL
PARCEL LINE**
MAr I to—<—MAP#
/ MAP 4 21 F NUMBER
E HOUSE HOUSE
#1860 NUMBER
� 6 - 9
f - 2 FOOT CONTOUR LINE
—te— 10 FOOT CONTOUR LINE
O Elevation based on NGV029
I `�4.9 SPOT ELEVATION
STONE WALL
-X--X— FENCE
RETAINING WALL
` `�, t T......1...._}.....1.... RAIL ROAD TRACK
STONE JETTY
SWIMMING POOL
PORCH/DECK
� L�,J CI BUILDING/STRUCTURE DOCK/PIER
HYDRANT
VALVE O MANHOLE
t `•,, `~— _ O POST 0" FLAG POLE
! T O W N O F 8 A R N S T A 8 L E G E O G R A P N 1 C 1 N F O R M A T 1 O N S Y S T E M S U N 1 T p SIGN ® STORM DRAIN
N PRINTED SCALE:IN FEET p 0 p y graphic p ( p photographs y
,- _ *NOTE: This ma is an enlar ement of a **NOTE:The parcel lines are only ro hic representations DATA SOURCES:Plonimetria man-made features were interpreted from 1995 aerial b The lames
w f — _ I"=100'scale map and may NOT meet of property boundaries.They are not true locations,and W.Sewall Company.Topography and vegetation were interpreted from 1989 aerial photographs by GEOD 0 UTILITY POLE n TOWER
0 20 40 National Ma,Accuracy Standards at this do not represent actual relationships to physical objects Corporation. Plonimetria,topography,and vegetation were mopped to meet National Map Accuracy Standards
1 INCH=40 FEET* enlarged scal. on the map. at a scale of 1"=100'. Parcel lines were digitized from 2000 Town of Barnstable Assessor's tax maps. O UGHT POLE O ELECTRIC BOX
sa _
:.� °•. TOWN OF BARNSTABLE
BUILDING DEPARTMENT
t NsaaaT TOWN OFFICE BUILDING
� rua
°b j679• HYANNIS, MASS. 02601
1•
MEMO TO: Town Clerk
FROM: Building Department
DATE:
An Occupancy Permit has been issued' for the building authorized by
BuildingPermit $ ............ v.................... .. ................................................_...._...._..............._........._............_......../.
issuedto ......// . -�------........................-...... .. ................................................. . _. ..._ . _ _........._��._
Please release the performance bond. `
a '
O*THE TOWN OF BARNSTABLE 3 §AIS
Permit No. .
BUILDING DEPARTMENT
TOWN OFFICE BUILDING Cash
'Y9
• ''rauT HYANNIS,MASS.02601 Bond .......... 46
. l
CERTIFICATE OF USE AND OCCUPANCY
Issued to Mazel Realty Trust
Address Lot #45, 10 Viola 'Lane
Marstons Mills, Mass.
USE GROUP FIRE GRADING OCCUPANCY LOAD
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.
.......June..19......... 19.....90........ .....4....... ac...oi...... ....
Buildi g Inspect
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..rJ OF BARNSTABLE, MASSACHUSETTS BUILDING PERMIT
DATE 19 PERMIT' NO.
APPLICANT - ADUHESS !)'j
(NO.) (STREET) (CONTR'S LICENSE)
P,.1`,r' - I NUMBER OF
PERMIT TO i
(_) STORY DWELLING UNITS
(TYPE OF IMPROVEMENT) NO. (PROPOSED USE)
- - ZONING y:
AT (LOCATION) DISTRICT
(NO.) (STREET)
BETWEEN AND
(CROSS STREET) (CROSS STREET)
LOT
SUBDIVISION LOT BLOCK SIZE
BUILDING IS TO BE FT. WIDE BY FT. LONG BY FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION
TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION
(TYPE)
REMARKS:
AREA OR ,. FEE
VOLUME ESTIMATED COST
(CUBIC/SOUARE FEET)
OWNER
>� BUILDING DEPT.
ADDRESS BY P.
i (-.
THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET, ALLEY OR SIDEWALK OR ANY PART THEREOF. EITHER TEMPORARILY OR
PERMANENTLY. ENCROACHMENTS ON PUBLIC PROPERTY, NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE, MUST BE AP-
PROVED BY THE JURISDICTION. STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED
FROM THE DEPARTMENT OF PUBLIC WORKS. THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS
OF ANY APPLICABLE SUBDIVISION RESTRICTIONS.
MINIMUM OF THREE CALL APPROVED PLANS MUST BE RETAINED ON JOB AND THIS WHERE APPLICABLE SEPARATE
INSPECTIONS REQUIRED FOR CARD KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN PERMITS ARE REQUIRED FOR
ALL CONSTRUCTION WORK: ELECTRICAL, PLUMBING AND
1. FOUNDATIONS OR FOOTINGS. MADE. WHERE A CERTIFICATE OF OCCUPANCY IS RE- MECHANICAL INSTALLATIONS.
2. PRIOR TO COVERING STRUCTURAL QUIRED,SUCH BUILDING SHALLNOTBE OCCUPIED UNTIL
MINAL INSPECTION
TI 70 LATHE FINAL INSPECTION HAS BEEN MADE.
3. FINAL INSPECTION BEFORE
OCCUPANCY.
POST THIS CARD SO IT IS VISIBLE FROM STREET
BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS
O'er
2 2 .
2
�1 5 HEATING INSPECTION APPROVALS ENGINEERING DEPARTMENT
S i tZT 7U C4LJ4OTHER eve r�
BOARD
Li
WORK SHALL NOT PROCEED UNTIL THE INSPEC- PERMIT 'A!LL BECOME NULL AND VOID IF CONSTRUCTION INSPECTIONS INDICATED ON THIS CARD CAN BE
TOR HAS APPROVED THE VARIODUS STAGES OF I WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE ARRANGED FOR BY TELEPHONE OR WRITTEN
CONSTRUCTION. PERMIT IS ISSUED AS NOTED ABOVE. NOTIFICATION.
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Assessor's office(1st Floor):
Assessor's map and lot number • V7 �� On - ' `� 5�y O*TH E TO
Board of Health(3rd floor): � � pp CODE
Q�
Sewage Permit number -�5�' .�T 1E?M u"® •n®Ns
�a . Z BLRJSTSDLE
Engineering Department(3rd floor): rjS • 'g� T f NAM
House numberi63q
Definitive Plan Approved by Planning Board 1 19 is b o MAY d
APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only
TOWN OF BARNSTABLE
BUILDING ' INSPECTOR
APPLICATION FOR PERMIT TO 7—
G
TYPE OF CONSTRUCTION in z> 11e—=
19
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location O 7//�L%9 .qn/� ��/✓/f
Proposed Use C-5y,
Zoning District Fire District
Name of Owner A9A Address ��P�S
Name of Builder �'�°9�J f.S" �m/� Address ,��t/cS'T�94G E
Name of Architect �T Address
Number of Rooms Foundation /`ay,E��� C�of✓e�E'�1PE
Exterior �«�a�A'e� �'�� `�' Roofing
Floors ��2ec>W oo O Interior
Heating G�i� Plumbing �TS
Fi lace, Approximate Cost
1� \ Area A�
Diagram of Lot and Building with Dimensions Fee
V
ET J-3!z,
• J
'NOV 3 198�
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction.
Name
Construction Supervisor's License
MAZEL REALTY TRUST
BUILD
No 3.3 6 8 6:. Permit For DWELLING -
Single family dwelling
Location 10 Viola Lane
Lot #45)
Marstons Mills
pwner
-Mazel Realty Trust
Type of Construction Wood frame
Plot Lot
Permit Granted April 19 19 90
Date of Inspection 19 ;
�* ri . /f /1 //
I �-J //f-/ i� (/
Cf�Cdrplet d (((��� 19
� � 71,
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Assessor's office(1st Floor):
Assessor's map and lot number � .o 3 t)0 (1()q � Q�o*TNe
Board of Health(3rd floor): Q
Sewage Permit number /1 7 -(��J6 f •
J, Z BASd9TADLL i
Engineering Department(3rd floor): �o rasa
�y F :
House number � fi'' �2� As ,. ';� � o t639.
Definitive Plan Approved by Planning Board 3 - 2 19 •Sb �0 MAY
APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only,
TOWN--. . OF 1 BARNSTABLE , +t`
BUILDING INSPECTOR
L�2 i
APPLICATION FOR PERMIT TO c _ 8/✓`4 9.E�U
TYPE OF CONSTRUCTION {
�q I
19 —�
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location
Proposed Use az E /� y
Zoning District �E�S'/1�E� T C Fire District
Name of Owner E4 L>X ;re yST Address
Name of Builder -- •��,5' �h'1/T1� Address -�.Pit/�S'T�QLE -
Name of Architect Address
Number of Rooms Foundation ���✓c,,eCr45
Exterior C'«�Qd�'�� w'�' �' Roofing ����•�G
Floors Interior
Heating c.9 Plumbing
Fireplace ENE Approximate Cost �110,/ aoCD
Area
Diagram of Lot and Building.with Dimensions Fee
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction.
. Name
Construction Supervisor's License OOSI
MAZEL REALTY TRUST 4
A=043-006. 009
BUILD
No 33686 Permit For DWELLING
Sinqle family dw 11 ; nq
Location 10- Viola Lane
(Lot #4:5)
Marstons Mills
Owner Mazel "Realty TriiGt-
Type of Construct.ion Wood frame
Plot Lot -
Permit Granted Anti 1 1 9 19 90
Date of Inspection 19
Date Completed 19
PERMIT COMPLETED 1/1/q1