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HomeMy WebLinkAbout0082 WAKEBY ROAD ^ ^ .. a -. 0 0 o.: . a p° n "1� Town of Barnstable # Regulatory Services Fee 6 mo d_from issue date • = g rY + + + ■AEWSfABIE,KAM • Thomas F.Geiler,Director Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY (j ) Not Valid without Red X-Press Imprint Map/parcel Number 00014 01jV &I—Z Property Address 2 it d Ay� n I l /1(6/_T TI esidential Value of Work �2�J'� Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address dip✓ f '2- �/of f"1 677P, Contractor's Nam e��Q j�y� E.j fCJ p Telephone Number Home Improvement Contractor License#(if applicable) j•S7 Y O Construction Supervisor's License#(if applicable) ,57/y4 w p �©U ISivasT orkman's Compensation Insurance Check one: ❑ I am a sole proprietor MAY 10 2012 ❑ I am the Homeowner [.have Worker's Compensation Insurance Insurance Company Name h v/, u TOWN OF BARNSTABI.E Workman's Comp.Policy# 6 3 k Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box)Fr-Re-roof �' / (hurricane nailed)(stripping old shingles) All_construction debris will betaken to�✓�a 5. L ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of th ome Improvement Contractors License&Construction Supervisors License is m SIGNATURE: C:\Users\decollik pDa \Local\Microsoft\Windows\Temporary Intemet Files\ContenLOutlook\DDV87AAZ\E}CPRESS.doc Revised 072110 i + w The Commonwealth of Massachusetts Deparh►►ent of Industrial Accidents Office of Investigatious 600 Washington Street Boston,MA 02111 wivrn mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Ledbl♦' Name(Busine organization/Individual)_ J 00m) ])ALT E: Lj O Address: 92, L41r_ City/State/Zip: p7'K rr IT 0 oi43_,5' Phone 4- 7 7 y 736 D6J Are yo an employer?Check the appropriate box: T project re 4. am a general contractor an }�e of ect p I (required): 1. I am a employer with 7__ 4. I l tt d I g 6- ❑New construction employees(full and/or part-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 S. ❑Demolition w for me in an capacity- employees and have workers' o>jnag Y aP h'- 9. ❑Building addition [No workers'comp.insurance comp.insurance.= wed) 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeotamer doing all work officers have exercised their 111]P lum repairs or additions myself[No workers'comp. right of exemption per MGL 12- airs insurance requiredJ y c. 152,§1(4),and ure have no employees-[No workers' 13.❑Other comp.insurance required.] *Any applicant that checks boa#1 u=also fill out the section below showing their woikers'compensation policy information. 7 Homeowners who submit this of idari indicating they are doing all wo*and then hie outside contractors most submit a new affidarit indicating such. Contmctors 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 bare employees,they nun provide their workers'comp.policy number. I ant an employer that is providing workers'comp usation insurance for my employees. Below is the policy and job site information. C Insurance Company Name: r G( Policy"P or Self-ins.Lic.4k Expiration Date: Job Site Address: Z kfgmv AIU, City/State/Zip: SMa Attach a copy of the workers'con ensation 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 S 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 forurarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c to i►rs grid Retialties of pesjtiry lliat the utforniatiort provided is true and correct. Si tore: / �y / Date: Z— Phone '. O Q I� Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/Ucense 0 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#: ACC? CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) `:� 05/10/2012 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 NAME: Mark Sylvia Insurance Agency PHONE • 508 428-0440 FAX 771 Main Street A/c No): EMAIL ADDRESS: Ostervllle,MA 02655 INSURERS AFFORDING COVERAGE NAIC# INSURER A: Farm Family Casualty Insurance INSURED INSURER B John Dalterio 112 Captain Samadrus Road INSURER C: Cotuit,MA 02635 INSURER D: 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS A GENERAL LIABILITY 2001XO587 9/16/2011 9/16/2012 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES Ea occurrence $ 50,000 CLAIMS-MADE �OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 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 ( ) NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS AND EMPLOYERS'LIABILITY COMPENSATION Y/N 2001 W6395 9/17/2011 9/17/2012 X WC T TU-TORY LIMITS OTH- ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? � N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ 100,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CARPENTRY JOHN DALTERIO IS COVERED BY THE WORKERS COMPENSATION POLICY JOB LOCATION:82 WAKEBY ROAD,MARSTONS MILLS,MA CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Town of Barnstable THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD �I • tAexsrnau, s, Town of Barnstable Regulatory Services Thomas F.Geiler,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I T)A NA L�A J 6 N wd P-7 ,as Owner of the subject property hereby authorize J()I+A) I_-rm l V to act on my behalf, in all matters relative to work authorized by this building permit application for: J > ,l s (Address o Job) ate, yr /Z Signature of Owner Date DANA LMS16N W514 Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\decollikWppData\Local\ icrosoft\Windows\Temporary Intemet Files\Content.Outlook\DDV87AAZ\EXPRESS.doc Revised 072110 ® `�f 1�an rs&BuS�ess u an'�one License or.registration valid fur individu1 use only Uffice o onsumer g kiTSTOM HOME IMPROVEMENT CONTRACTOR before ttse expiration date. If found return to: Regstration: 4a157407 Type: Office of Consumer Affairs and Business Regulation � , 10 Park Plaza-Suite 5170 Expiration: 10j1a013 DBA Boston.:h1A 02116 BUIL 1J —` ' j lei _ �=r 11`�"• t• ! •,� JOHN DALTEPCIO JIB 112 CAPTAIN SAMiRi�S'-RO'/ COTUIT,-MA 02635 Undersecretary ( Not valid%vithout idnature IVlassacbusetts- Department of Public Safety Board of Building Regulations and Standard~ Construction Supervisor License j License: CS 51144 JOHN D DALTERIO JR ' 112 CAPTAIN SAMADRUS RD k COTUIT, MA 02635 I I Expiration: 10/6/2012 j ('ununissiuncv Trii: i 6426 �oF VE rti Town of Barnstable permit4 Expires 6 mouths frorn issue dale Regulatory Services Fee -v MAS& $ Thomas F. Geiler,Director �p 0.19. A�0 rED MA't Building Division L Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: -508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without�?ed X-Press Imprint Map/parcel Number 7 J 1(O Property Address �� G/ 1� "� sr � M Lesidential Value of Work Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address 4-59 l te4VEW 0o94 gz h/4;4e-B q 71) /fit!GI SYyt Contractor's Name. J 0 P", T T&fl-t o 2 Telephone Number 77`/ 93 b D d/`/ Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) 0 P�rorkman's Compensation Insurance MAY — 3 2010 Check one: ❑ I am a sole proprietor TOWN (�� BARNSTASL.F' ❑ I am the Homeowner eI have Worker's Compensation Insurance b Insurance Company Name r/i'1Z1A I L� C6.s"jam Workman's Comp.Policy# 2-00/ it/6 3 Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) Re-side # of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum .44)# of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of th Home Improvement Contractors License & Construction Supervisors License is requt 7 d. SIGNATURE: i The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations a 600 YYashington Street Boston, MA 02111 www.mnss.gov/dia Workers' Compensation Insurance Affidavit: )Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/OrganizationAndividua^^l):Jd#r✓ /Dfii m.r ro s)1? C&-s,-7� °�dS Address: t��- �L�'�S;b t S r City/Stat Zip: l Phone #: 7�•-�3�-a Ll Are y an employer? Check the appropriate box: Type of project(required): 1. I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hued the sub-contractors 6. ❑New construction2.❑ 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' Y9, ❑ Building addition [No workers' comp. insurance comp. insurance.$ 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 1 l.❑Plumbing repairs or additions m s0f,..[No.w-or%eT5'_comp..................._.., right`of exemption per MGL Y - _ 12.0_Roof.repairs........-, . .. _.. .._..._ insurance required.] t Ell 52, §1(4), and we have no .SJ,P10J- employees. [No workers' 13.�Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they 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: 61�14 t h Policy#or Self-ins. Lic.#: 200/ W 43I Expiration Date: Job Site Address: lal4yeal K City/State/Zip:/h*5�iilW� ®�6 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 rce �� r the sins and penalties ofperjury that the information provided a ove i true and correct.Si nature: r I A Date: Phone#• ?7 V D 3 9 �bf" t 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 Phrinp I I Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for.their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the receiver or 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-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 artners are not re aired to c workers coin ensation insurance.' If an LLC of LPl'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 wwtiv.mass.gov/dia �f oFTHE Tpk Town of Barnstable Regulatory Services rMASS.. Thomas F. Geiler,Director Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.b arnsta ble.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder. I, �Q� T �2fh/Lci✓h/� , as Owner of the subject property hereby authorize �e*f -j Rio it to act on my behalf, in all matters relative to work authorized by this building permit application for: ( ddress of Job) S'k4AUe f Owner ate lte mn wog -T-q P�int Name OT If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the,reverse side. Q:FORMS:OWN ERPERM IS S ION ' i Town of Barnstable P�oF IKE y� i o regulatory Services • RAsrtsrasLe, • Thomas F. Geiler,Director Mass. �g ,A ��� Building Division 'let 39. a Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barristable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: 10B LOCATION: number street .village "HOMEOWNER": name home phone t{ work phone/1 CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is,or is intended to be, a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned "homeowner"assumes responsibility for compliance with the'State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a forn-/certification for use in your community. Q:\WPFILES\FORM S\homeez empt.DOC ?4/30/2010 15:07 5084209227 MARK W SYLVIA PAGE 01 CERTIFICATE OF LIABILITY INSURANCE F--M(1MM[IMwVVYn 2a10 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, EXItI D OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE.A CONTRACT BETWEEN THE ISSUING INSURER($), ALITHOR12ED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the poRdy(i'es)mast he endorsed. If SUBROGATION IS WAIVED,subject to the terms and Cond'Itfons of the policy,certain potioies may require an endorsement. A statement on this certificate does not Confer rights to the certificate holder In lieu of such endorse s. PUCER CONTACT Mark Sylvia Insur'anto PHONE Am Ferrer! Y� Agency PMONE IVAX 771 Main Street =(%8)428-0440 r-_.. 1 IAIC.NoLLO&).4ad-9227 E 0A'R�ela:mark merles Ivrainsurance,ccm Ostenrlile,MA 02655 PRODUCER 0MIERI1D.6 _._- -- INGURER(S)AFMROING COVERAGE NAIC d INSURED INSURER A; ohn Dafterio 112 Captain Samadrus Road INSURER S: Cotuit,MA 02635 IMwRER C: INSURER D: Fwrr,FarRi Ca9ualy Insurance — INSUREa E: _ — IN9UREk F•' COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES of INSURANCE LISTED BELOW HAVE 13EE_N 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, E XQLUSIONS ARID CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS_. us EFF L�ut TYVE OF INSURANCE Mw POWCY NUYRJ D NO R(MTY9 GENERAL,LJAWLrrY EACH OCCURRENCE 3 COrAMERGAI QENEiiAI LIABILITY PREm r {EA occu[Lepcg}— 6 CLAIMS-MADE OCCUR MED EXP one S PERSONAL,ADV INJURY $ CENERALAGG!%GAg'E s .. I.AGGREGATE LRdrrAPPLIES PER: PRODUCTS-COItPIOP AGG 3 POLICYJECX PRO— _.. AUTOMOBILE UABI nY COMSINEO SIN13LE LIFAIT ANY AUTO (Esswidenk) _ b ALL OWNED AUTOS BODILY INJURY(PRr pemm) R � .- .•., BODILY INJURY(Per swidam) 5 SCHEDULED AUTOS _ HIRED AUTOS PROPERTY OwAGE a (Per aeelmors() NON-WuNEDA4rrOS g S UMBRELLA LWe OCCUR EACH OCCURRENCE $ uA6 CLAssrs•n�nDE AGGREGATE~ 4 DE:OLICTISLE I - -•� RETENTION 9 D WORKERS COMPENSATION 2001 W6395 9/11PZOOt3 s/i7/20,a WC 8T'ATU- oTH $ BI AND ENPLOTERw LIAIJTY YIN ANY PROPP.IETORIPARTNERfEXECUTIVE $ 1000�OFFICMIEMBEREXCLUDED? NIA E,L.E:ACHACCIDENT (MRnddae In MR)and E,L DISEASE•EA EMPLOYE E 500,000 If yea,Caeaibe imdq DESCRIPTION OF OPflRATICNs bele.r E.L.DISEASE•POLICY LIHtr S 100.000 DPBCElI Ir"OFOPBRATIONS I LOGATMS I M[CLES(AHach ACORD IM.Addffialul Remwks B.,h.dute,N mm go".M IeRol" Job LoCation.82 Wakeby Rd Marstans Mills,MA 026M John Dalterle is included under coverage of Workers Compensation policy listed, CERTIFICATE HOLDER CANCELLATION TOWN OF 13ARNSTABLE SHOULD ANV OF THE ABOVE DESCRIBED POLICIES BE:CANCELIM BEFORE 200 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Hyannis,MA 02601 ACCORDANCE MTN TH--POLICY 1rROViSIONS. AUTHOINMO REPRESENTATIVE 01998-mg ACORD CORPORATION. All rights reserved. ACORD 26(2009109) The ACORD name and logo are registered marts of ACORD ✓1ae C�a.,intanulea a ✓Cfaz:aclzrcce� License or registration valid for individal use on Office of Consumer Affairs&Business Regulation regtstra only m _ - HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 157407 Type: Office of Consumer Affairs and Business Regulation Expiration: 10/1/2011 DBA 10 Park Plana-Suite 5170 :. Boston,MA 02116 J.P`CUSTOM BUILDING JOHN DALTERIO:JR; - f 112 CAPTAIN SAMADRUS RD. COTUIT.MA 02635 Undersecretary 116tvalid without si tare �- Massachusetts- Department of PubliC SdelY ?1W Board of Buililin!J Relgulations and Standards WJ Construction Supervisor License License: CS 51144 Restricted to: 00 JOHN D DALTERIO JR ' 112 CAPTAIN SAMADRUS RD COTUIT,MA 02635 Expiration: 1016WO l °� TOWN OF BARNSTABLE . * iARNSTABLE, • MASS. Application Ref: 200901141 20090378 Issue Date: 03/23/09 Applicant: LEAVENWORTH, ROBERT D Proposed Use: SINGLE FAMILY HOME Permit Type: SHEDS 120 SQ FT &UNDER Permit Fee $ 25.00 - Location 82 WAKEBY ROAD Map Parcel 043016 Town MARSTONS MILLS Zoning District RF Contractor PROPERTY OWNER Remarks 8X12 SHED Owner: LEAVENWORTH; ROBERT D Address: PO BOX 303 s � MARSTONS MILLS, MA 02648 � � To lrh Issued By: RM ;: PO: :T.T..Y ARb:.S: :.TAT..I vT TBLE>FR. M.T1E SEE:: : :::> <:> ::;:::::.>::::::<:;:>::::>::>::: xx _......................::..::.:.................... ...... ........ . .. ........_. ... _.S ...... IS..0 .. . ....._.0..._.. _ ........_5.........S.. O..._... .. _.. .T.._ .._.' ..::................................................................. Town of Barnstable �0*THE p� P o• Regulatory Service$,: AW,15.r'ABLE Thomas F. Geiler,Director BARNSr'ABr E, 6 9 � Building Divisionffl MAR 2*0 AM 8: 46 rFfl h+Ar Tom Perry,Building Commissioner 200 Main Street, Hyannis, MA 02601 www,town.barnstable.ma.us� OiVISION Office: 508-862-4038 Fax: 508-790-623( PERMIT# ����� �� FEE: $ SHED REGISTRATION 120 square feet or less (JA j /MST00s dYl i c— s Location of shed(addres's) Village q2.9 -Zoo g. Nit so g- t4-z - 7o Property owner's name Telephone number Size of Shed Map ar/P cel# . igenature Date Hyannis Main Street Waterfront Historic District? h� O Old King's Highway Historic District Comrission jurisdiction? 1� d Conservation Commission(signature is required) / Sign off hours for Conservation 8:0.0-9:30 &3.:30-4:30 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 REV:042506 N� 0_p tHE TO{y�.w ; The Town of Barnstable P� BARNSTABLE:•: Department of Health Safety and Environmental Services , 9 MASS. 0P 6}9• �0 P�eD MP+� Building Division 367 Main Street, Hyannis, MA 02601 Office: 508-862-4038 Fax: 508-790-6230 PLAN REVIEW Owner: Map/Parcel: `e (.CIAf�FB` /� 'OW Builder: �� 5 // E-r9y��yW627-// - Project Address: � ,1�.. The following items)were,noted on reviewing: �2��� ��/t�G/FO2 ST Us /N 6 (� DDf-NT- < ,�-•-• � Yam' } r Reviewed by- Date: q:buildingArms:review i /yd NWP.°FTHE�° The Town of Barnstable Department of Health Safety and Environmental Services BARNSTABLE. 9 MASS. 0 039• �0 MFyp Building Division 367.Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 PLAN REVIEW Owner: l/S s Z �J�V/�dr a���Tf� Map/Parcel: Project Address: F02 "04 Builder: $S ��19d ,tciv6rLT// Thee following items were noted on reviewing: �/ l/V, 5/XC ef 2-5 X � � 'e�04o-av [:nE *0/L. 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The Town of Barnstable Regulatory Services Thomas F. Geiler, Director Building Division Peter F. DiMatteo, Building Commissioner 200 Main Street,Hyannis MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the,"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any,pre-existing owner-occupied buildin 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 exceptions,along with other requirements. -Type.of Work: S K l0 Estimated Cost T ,3 Address of Work: god '� (n L Ls' Owner's Name: Date of Application: I hereby certify that: Registration is not required for the following reason(s): E]Work excluded by law []Job Under$1,000 QB g not owner-occupied LtlOwner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT 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 is the agent of the owner: Date Contractor Name Registration No. OR q:forms:Affidav :rev-122001 t r. , .t 1 RESIDENTIAL: SHEDS - POOLS-DECKS-OPEN PORCHES- GAZEBOS DETACHED GARAGES FEE VALUE WORKSHEET ACCESSORY STRUCTURES >120 sq.ft. (Sheds,detached garages,gazebos,etc.) . >120 sf-500 sf $'35.00 $ C,0 >500 sf-750'sf 50.00 $ >750 sf- 1000 sf 75.00 $ >1000 sf- 1500 sf 100.00 $ >1500 sf—USE NEW BUILDING PERMIT APPLICATION DECKS - x$30.00= $ (Number) PORCHES x$30.00= $ (Number) IN GROUND SWIMMING POOL $60.00 $ ABOVE GROUND SWIMMING POOL $25.00 $ RELOCATIONIMOVING $150.00 $ (Plus above fee if applicable) PERMIT FEE $ - e d O , t Q:focros:dkcost eff:082301 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 3 Parcel & Permit# (p Health Division nror e, q Date Issued ©Z Conservation Division Ox Fee 100 Tax Collector Treasurer OI6 8� o 6 Planning Dept. Ile y'c Date Definitive Plan Approved by Planning Board I cp Historic-OKH Preservation/Hyannis c'n� 7 Project Street Address �'�J�'604 `� Village ft 2//5I C 5 0 U—S N Owner 0or/51-fF-4! UYWEI, W* Address g, vro Telephone -5n S — 42 � " 9024 Permit Request Square feet: 1 st floor: xi ing 66 proposed 2nd floor: existing proposed Total new Valuation - - Zoning District Flood Plain N O Groundwater Overlay Construction Type Lot Size ACK.65 Grandfathered: ❑Yes 4PI o If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure 31 YAS' 1�10 Historic House: ❑Yes No On Old King's Highway: ❑Yes ' 0/ Basement Type: ❑Full ❑Crawl 'Walkout Cl Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) 9� D Number of Baths: Full: existing new 0 Half:existing o new ° Number of Bedrooms: existing a new Total Room Count(not including baths): existing new b First Floor Room Count Heat Type and Fuel: ❑Gas O Oil R Electric ❑Other Central Air: Cl Yes Q o Fireplaces: Existing e�E New Existing wood/coal stove: ❑Yes & o Detached garage:O existing ❑new size_ Pool: ❑existing ❑new size -A3 Barn:O existing Cl new size N Attached garage:O existing O new size O Shed:®'existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes Ef"No If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION Name .5 14�1C�� �dJL�p Et�) C&��Telephone Number Address �rl 1�Fd�[e � License# 1 (.L� Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE f no DATE / � FOR OFFICIAL USE ONLY o 9 PERMIT NO. DATE ISSUED MAP/PARCEL NO. - ' ADDRESS VILLAGE c. OWNER ,., , k DATE OF INSPECTION: r' f FOUNDATION FRAME INSULATION ti _ FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL <41 GAS: -,.ROUGH. FINAL FINAL BUILDING r DATE CLOSED OUT ASSOCIATION PLAN NO. gF 4 .r _ SHED REGISTRATION ,2-C) location of shed(address) o property owner's name C>X 1 2' size of shed signature date Old King's Highway Historic District Commission jurisdiction? THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN shed r • �.r qL-333 w��f� mortgpge inspection plan aalakass '� Sz w+�l�.cr�tir �A.o slp �Z'4'.3 4 vivawe Naw lawnZtisr�3�G Qwnof 46c1�T Lt=A�lE�twc�fLTH DM 3s'4-�4- pG 3�(-o assessors mop =parcel `�' plan bWk� ppga =lot I 0 U- 4 J Y .t A/yam 53,k N ti 4i T SCALE: 1 LNCH= This is not an 1NSTRUMLNT survey. The dwelling as shown GQMPU64 with kVU BANK USE ONLY. the 'Loning by-law NOT FOR CONSTRUCTION. FENCING-. DEED buUdiny setback requirements When ULSCIUL"LIONS-, RECORDING-. I'KOPElaY UNE con6tructed and there are no visible D4FINrVION-. LOT OR LOT CO1/1r"Fe Aii M*s eabement�otencroaChrllenti�therthan OR bUIWING OFr b=11 Utilities or as.noted on the plan- The -reyabN dwelling does not lie in ajlood hazard zone,as specLjied on con nuniiy Pane, 14 � r mate AuE•�.�s' R. i�(8'S � �repated e,�1�i�eiy for Sumycr QJALA A-' 3a8 �'�1 LANU 6J, • down cap e °g eating land surveyors, civil engineers (508)362.4541•FAX 362.9880 939 MOIn Streot•Yarmoutnport, MA U75 TOP FNDN, AT EL. 73.0' SYSTEM PROFILE ACCESS COVER TO WITHIN 6' OF FIN. GRADE (NOT TO SCALE) . MINIMUM .75' OF COVER OVER PRECAST /` ACCESS COVER (WATERTIGHT) TO WITHIN 6' OF FIN. GRADE 2% SLOPE REQUIRED OVER'SY; s 2' DOUBLE. WASHED PEAS1 RUN PIPE LEVEL /-'FOR FIRST 2' EXISTING_,= GALLON SEPTIC 66.3't • TANK (H- lO ) GAS (REUSE EXIST.) ; BAFFFL 63.67' �� .5 o63.171 D D o C7 C 63.17 C70ED0 0 0C 6' CRUSHED STONE OR MECHANICAL 0 0 0 0 17-1 0 C COMPACTION. (15,221 123) R&O2' C7 C1 0 0 0 o C DEPTH OF FLOW = 4' 3.3 MIN TEE SIZES c % SLOPE) (-L-/ SLOPE) 3/4' TO 1 1/2' DOUBLE WA INLET DEPTH = 10" 1 OUTLET DEPTH 14" FOUNDATION- EXIST SEPTIC TANK 78' D' BOX 13' 97. 8's s s� \ �+ 53.5 ss ss � s� s ( + 5. 6,0 _I_ 2.3 6 + 69.8 6' *CONTRACT( +60.7 TO S' BENE 3.3 OF INSTALL, rn I12 0 K + 5. 68.0 71.1 7.7 Opii M SHED 9.9 7 C. APPLE 65.7,,. (SAVE -70 60 0 v + 7 7 .7 >> 9.6 L#P 7.8 I FLA STONE BENCH WA L 73 9 RET WA \LLS Q 7•l FOUNDATION ARK TOP OF GA EN (SAVE) EL. = 73.0' 0 N O 74.5 O O 7.7 0 ti I ' n 6 i . I SNE� + 4.3 + 71.4 7�.� f DECK x I + 72.4 TOP FNDN 73.0' 9.6 5 EXIST. DWELL. 178.1 0 + 6.2 .r 71. + .3 ** THIS IS AN ASSUMED WATERLINE LOCATION (NOT MARKED AT TIM� TEST HOLE). CONFIRM LOCATION; PRIOR TO EXCAVATION O 7 + 3�� 9.4 7 v ~v �p O) ►� + 76.4 75. S.r ^ib 76.3 5.0 I GRAVEL DRI E / PARKING I 74.5 , I • s i I 75.7 R=740.00' © .5 6.0 25.00' S7 .2 77.0 77.0 L=1 00.00' _ _ 76.4 - - - - - - + 76.9 i WAKES Y ROAD TOP FNDN. AT EL. 73.0' SYSTEM PROFILE TEST HOLE LD(-S ACCESS COVER TO WITHIN 6' OF FIN. GRADE (NOT TO SCALE) ®� ACCESS COVER (WATERTIGHT) TO ENGINEER: ARNE H. OJALA, PE MINIMUM .75' OF COVER OVER PRECAST /` WITHIN 6' OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM 67 O' DAVID STANTON WITNESS: 2' DOUBLE WASHED PEASTON- DATE 4/11/02 RUN PIPE LEVEL FOR FIRST P 3' MAX. PERC. RATE _ < 2 MIN/INCH - EXISTING_.].QQ4 -- c^ GALLON SEPTIC 66.3'f 64.0' I LOCUS TANK (H- lO > GAS CLASS_ SOILS P# +0210 ., nnno ooa � PKEg� (REUSE EXIST.) BAFFLE 63.67 00 0 63,17 0 0 0 0 ED m 0 0 C7 r4' AROUND � 6' CRUSHED STONE OR MECHANICAL n a a O O 0 U 2' O O O C7 0 O 1=1 13 K aaY COMPACTION. (15,221 C2]> 0 61.17 Q ELEV. DEPTH OF FLOW = 4' MIN( 3.3i SLOPE) (� SLOPE) 3/4' T❑ 1 1/2' DOUBLE WASHED STONE 0/A �"- TEE SIZES SI _ INLET DEPTH = 10 g" 10YR 3/1 OUTLET DEPTH = 14" LOCATION MAP NTS B EXIST Ll_ACHING f QUNDATION- SEPTIC TANK 78' D' BOX 13' LOAM --IF�,CIL?TY 5' 20" 10YR 5/4 ASSESSORS MAP 43 PARCEL 16 ells� 6� 6' 97. 8' 6 \ SS � + 53.5 S C1 UNSUIT. LOAM + 5. S s'9 6, 61 56.17'* 40" 2.5Y 5/4 64.17' 2.3 6, st + 69.8 6 4 �\s,9 *CONTRACTOF TO, CONFIRM SUITAB:E S0ILS46#6. PERC L 2 \61 TO 5 BENEA :"'i LEACHING FACILITY AT TIME CMS ++ 60.7 OF INSTALLA JN 3.3 ' .5Y 5/6 \� 12 0 K + v \' � 5. 6S.o 1 C" 57.5' 71.1 7.7 � JO WATER _ 2 ENCOONTERED ND T E S 00 ��i g'�,drd r- 67:a Nj \ 99 SHED . .7 _- M \ \ \ 65,7 SF=PTrC DE",IGI (r,APt ;�� N'•T ,aLi ��;'F� , . n � I c�%�AA •-,II^� t 3 C AB APPLE - �: J \ l (Z>AVL) 70 DESIGN FLOW; 3_ BEDROOMS (110 GPD) = 330 GP J ❑• MUNICIPAL WATER I<- EXISTING 6o 0 ally USEA 330 GPD DESIGN FLOW 3. MINIMUM PIPE PITCH TO BE 1/8' PER FOOT. . � \ n . DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASH❑ H-10 + 7 7 •7 >> 9 7.8 } SEPTIC TANK: 330 GPD ( 2 660 ` ��6 �� � ) = `..i. PIPE JOINTS TO BE MADE WATERTIGHT. 73.9 FLAGSTONE Q 71 BENCH MARK - TOP OF USE A 1000 GALLON SEPTIC TANK (RE-USE EXISTING) G. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. BR K �. RET. WALLS FOUNDATION W X EL 73.0A L (SAVE) LEACHING: ENVIRONMENTAL CODE TITLE V. GA EN `, O N = 2(25 + 12.83) 2 (.74) = 112 7. THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT \ o SIDES: TO BE USED FOR ANY OTHER PURPOSE. 74.5\ --� O 7.7\ 0 25 x 12.83 (.74 7 o BOTTOM: _ _�3__ 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4' PVC. TOTAL: 472 S.F. 349 GPD `3. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT SHED +,�4.3 + 71.4 DECK \x USE (2) 500 GAL. LEACHING CHAMBERS (ACME OR INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED • FROM BOARD OF HEALTH. EQUAL) WITH 4' STONE ALL AROUND 10. PUMP & REMOVE (OR FILL W/CLEAN SAND) EXISTING LEACH PIT I \72.4 TOP FNDN 73.0' 9.6 EXIST. DWELL. I 78 O 1 LEGEND + 6.2 �, 71� + .3 ** TITLE 5 SITE PLAN THIS IS AN ASSUMED WATERLINE LOCATION (NOT MARKED AT TIME OF 100.0 PROPOSED SPOT ELEVATION 01_ r� - TEST HOLE). CONFIRM LOCATION 82 W A K E B Y ROAD PRIOR TO EXCAVATION 100x0 EXISTING SPOT ELEVATION + �� /� � 10o IN T MILLS) 0 7 HE TOWN OF: 2\ PROPOSED CONTOUR ( MARSTONS B A R N S TA B L E 9.4 + 76.4 � yy 20 i, �� 100 EXISTING CONTOUR PREPARED FOR: SHERRI LEAVENWORTH Q� 76.3 5.0 �-� __� 20 0 20 40 60 GRAVEL DRI E PARKING 745 BOARD OF HEALTH R=740.00' ©ir�•s \zlm60 APPROVED DATE MA SCALE: 1" = 20' DATE: APRIL 19, 2002 75.7 \ L -1 00 00' 77.0 off 508-362-4541 77.0 7fi 8 Fox 5WS 362-98M ROAD down cape engineering,, inc, ,!�U�i,� �+ 1 o ARNE H. WAKES Y �%� ARNE <, OJALA CIVIL ENGINEERS o o f CIVIL I H OJLA LAND SURVEYORS zG 1'0. 2 4t1 939 vain st. yarmouth, rya 02675 ; 92--333 769 'A) 1 H. OJALA, . P.L.S. DATE