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0195 WALNUT STREET
I - ---- - - - 0 v 0 ..................... �".�• .!'w+w• R� �^.ZT w-.r-- .�w....�_. .-�• r R.,,.a..�.,:... .� ,. .. . T .n ,, .A-: n.-�1"'+.�`y^ .ice .+Pr+F.-+�. IR TRH.. 49 Herring Pond Road I Buzzards Bay,MA 02532 P.5o8-888-i74o F.508-833-3377 Resolution E N E R G Y May 14, 2015 Thomas Perry,CBO ? p -n Town of Barnstable, Building Division 200 Main Street ��`� " , j 1 Hyannis, MA 02601 �- '"''�' M RE: Insulation/Weatherization Permits Dear Mr. Perry: ' This affidavit is to certify that all work completed for insulation work at: • Dianne Miller, 195'Wainut St, Marstons Mills#201304304 /has been inspected by a certified Building Performance Institute (BPI) Inspector. All worperformed meets or exceeds Federal &State requirement. inc rely, �� Richard Fournier TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Q Map' Parcel �7 Application Health Division Date Issued n2 l Conservation Division Application Fee�Sy Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/Hyannis to Project Street Address n Villagel�.s!-ate Owner 1�o b�c/i- 0i ann c. Mi lhe-r— Address 19C W aJn 0Z- y, Telephone CCU U D V! 3 Permit Request 1nL5-�(U 5 7 aZ s s. L4.1- cL_ e m I an I /a.U a 5. . aL A-Im c�ci UJ Il riS1c_4 : a c 4L �'1 Th.c� a 4/s� aL aAA A d-al- •- Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family W TWO Family Cl Multi-Family (# units) Age of Existing Structure Jg1(o Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new I Number of Bedrooms: existing _new r" Total Room Count (not including baths): existing new First Floor Room Count ,'feat Type and Fuel: ❑ Gas tail ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wo�/ al stove Cl Y�s ❑ No Q o • Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: xisting neza:;size Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other1 (31 v W a Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ . A Commercial ❑Yes ❑ No If yes, site plan review# rM Current Use Proposed Use co M APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name &Aanct ' Uric t rr Telephone Number �& ) Q Address Uq HcrC'i,-tS Nand 2-Cl License # Home Improvement Contractor# 7S-7 53 Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATUR DATE G ��4�!•� i FOR OFFICIAL USE ONLY APPLICATION# r DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE . h OWNER k DATE OF INSPECTION: .sFOUNDATION FRAME INSULATION . t e FIREPLACE F ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL S t r GAS: ROUGH FINAL �i FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. s r— ��e�onro+ra�uaen�C✓a�� /la:J:;rcc�c%�e%�a Office of Consumer Affairs&Business Regulation j SOME IMPROVEMENT CONTRACTOR registration: .175793 Type: j piration: ,,6/10i 5- Individual RICHARD'FOURNIER RICHARD FOURNIER;, 13 WILUAMS ST APT FAIRHAVEN,MA 02719 Undersecretary tlQfiny REr i.�i,:i �H'r Cirri 24A'?sS 31 wusr. aons-tructiur Supenisi�r . " Y _ License: CS-081;174 = RI ;P FOU3tNIER r E 105 CPNTRE ST- �4?; FAIRHAVIN M�F 02719 Commissioner .0312912014 � �-. 0 N T i I Co M ,I i l S i t i i The Commonwealth of Massachusetts Pnnt Form Department of Industrial Accidents Office of Investigations i 1 Congress Street,Suite 100 Boston, ALL 02114-2017 www massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aualicant Information Please Print Legibly Name (Business/Organization/Individual): /( i I n C Address: �lq 14erri115 2C1 City/State/Zip: 6t1U-circ(S 6aw 17119 odS3-1-Phone #: (5��� P�� - 17 L/D Are yo employer?Check the approp ate bog: Type of project(required): 1. I am a employer with'— 4. ❑ 1 am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling shipand have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' insurance.: 9. ❑ Building addition comp.[No workers' comp. insurance P• required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.El officers have exercised their I am a homeowner doing all work 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ R f repairs insurance required.] t c. 152,§1(4),and we have no employees. [No workers' 13NET Others 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: �nnd�ncnkj_t //&LV6/A, CO . Policy#or Self-ins.Lic.#: 46—F?J1 V29-b Expiration Date: Coyl Y/.;Lo) `/ Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the D insurance coverage verification. I do hereb ce under a awns and enaldes o er'u in that the ormadon provided above is true and correct. Si atur : --- - - --- Date- - -- Phone#: S� � ��— �L/ � ------------ Official ullonly. Do not write in this area,to be completed by city or town ofjk!aL City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: r ACORD CERTIFICATE OF LIABILITY INSURANCE 0 6/1 M//2 0 1 3 TM 06/17/2013 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: 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: Applied Risk Insurance Services, Inc. PHONE FAX 10825 Old Mill Rd AIC,No, Ext): (877)234-4420 (ac,No): (877)234-4421 Omaha, NB 68154 EMAIL ADDRESS: PRODUCER (877)234-4420 CUSTOMERID# INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURERA Continental Indemnity Co. 28258 INSURER B: Resolution Energy, Inc. INSURER C: 49 Herring Pond Rd Buzzards Bay, MA 02532-2226 INSURERD: INSURER E: CTL 1273 751100 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 ADD SUB POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/DD (MMIDD/YYYYI UN ITS GENERAL LIABILITY EACH OCCURRENCE COMMERCIAL GENERAL LIABILITY ❑❑ DAMAGE TO RENTED $ CLAIMS MADE OCCUR $ MED EXP(any oneperson) $ PERSONAL SADVINJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRO- PRODUCTS - O P GG $ POLICY F-IJECT LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO El❑ Ea acddent $ ALL OWNED AUTOS BODILY INJURY Perperson) $ SCHEDULED AUTOS ILY INJURY r 'd t $ HIRED AUTOS PROPERTY DAMAGE Paraoddent $ NON-OWNED AUTOS $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE ❑❑ AGGREGATE DEDUCTIBLE RETENTION $ $ WORKERS COMPENSATION X JT WCSTATU- 3TH- ANDEMPLOYERS'LIABILnY Y/N ER ANY A OFFICER/MEMBER EXCLUD D?ECUiIVE Y NIA 4 6-8 7 2 4 7 9-01-0 1 06/14/2013 06/14/2014 E.L.EACH ACCIDENT $ 500,000 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach Acord 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION Housing Assistance Corporation SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 460 West Main Street BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED Hyannis, MA 02601 IN ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Project Manager AUTHORIZED REPRESENTATIVE 1783118 ACORD 25 (2009/09) ©1988-2109 A ORD CORPORATION. All rights reserved Housing � Assistance Corporation Cape cod HOMEOWNER!RESIDENT WEATHERIZIR,TION WORK PERMIT&FUEL RELEASE-, PLEASE FILL OUT AND SIGN THIS FORM IF YOU ARE THE APPLICANT HOME OWNER. hereby consent to and agree that weatherization work may be done by the Weatherization Program of Housing Assistance Corporation (herein after referred-as 'Agencyl on the property located at: .ZQJ, A The weatherization work done will be-based-on prograaw vatic priorities.arid-availability-of-•funding--and-it may include all or some of the following measures: Weather-stripping &caulking of windows and doors, insulation of attics, sidewalls&basements, attic and other ventilation measures and possibly replacement of badly deteriorated windows. In consideration of the weatherization work to be-done at my home I agree to the following: 1. I give permission to the "Agency"its agents and employees to travel onto or across said property with such equipment and materials as may be necessary to perform weatherization work on said property. 2. The Housing Assistance Corporation reserves the right to inspect the fuel or utility bill for the weatherized unit on an ongoing basis for no more than five(5)years after the weatherization work is completed. I have read the pr ofIs agreerqe�t aT d and-freely give my consent. Home Owner: (Sig atur .Date: 1 %3Ir Agent: (signature) HAG approved Weatherization Company: Adam T.Incorporated All Cape Energy Altemative-Weafherizatiion Building Performance Contracting LLC Cape Cod Insulation Cape Save Frontier Energy Solutions Lohr Home Improvement Resolution Energy i�lm ,,,.e-tii ii�itabi;l:!i14i.,.;a r•.-if:ac:;t icx%:-�. ::-F- _'tl•X •.'• c.-r-�Q f.'.:�,r.• CHEVONNE A. PRATT A ® Account Executive DATE(MMroaY.Y.) CCIlfRVCERTII �--p Licensed Broker CE 6/26/13 THIS CERTIFICATE IS ISSUED AS A MA, 411 Route 28 N THE CERTIFICATE HOLDER THIS Clk CERTIFICATE DOES NOT AFFIRMATIVEI W.Yarmouth,MA 02673 ikGE AFFORDED BY THE POLICIES B660 ELOW. THIS CERTIFICATE OF INSUR CHAGNON 508-771-1135 ISSUING INSURER(S), AUTHORIZED EPRESENTATIVE OR PRODUCER,AND INSURANCE Fax 508-775 1135 PORTANT: If the certificate holder is a UBROGATION IS WAIVED,subject to the terms and conditions of the policy,ce AGENCY, INC. Post Office Square P Y ' Orleans,MA 02653 trtlfipte does not confer rights to the certificate holder in lieu of such endorsers 508-255-2623 PRODUCER ciainsurancecapecod.com Fax 508-240-2435 itt Chagnon Insurance Agency, IE FAx No: (508) 775-1135 PO Box 355 ADDRESS: chevonnepratt@ciainsurance.net 411 Route 28 INSURERS)AFFORDING COVERAGE NAIC N West Yarmouth, MA 02673 INSURERA:Commerce Insurance Com an INSURED INSURER B:AIM Mutual Insuracne Compan David S. Hodsdon, II INSURER C: DBA Atlantic Cape,Builders INSURERD: PO BOX 221 INSURERE: Yarmouthport, MA 02675 INSURERF, 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 ADDL SUER POLICY EFF POUCY EXP LTR TYPE OF INSURANCE _ IN SR WVD POLICY NUMBER MMIDDIY MMIDDIYYYY LINTS A GENERALLIABILITY BDVXZM 2/1/13 2/1/14 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO aENTED $ 100,000 CLAIMS41AADE OCCUR MED EXP(Anyone person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMITAPPLIESPER PRODUCTS-COMPIOPAGG $ 2,000,000 POLICY PRO LOC $ A UTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ BODILYINJURY(Perperson) $ LLOWNED SCHEDULED BODILY INJURY(Per accident) $ UTOS AUTOS NONOWNED PROPERTY DAMAGE $ IRED AUTOS _ AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION TO BE ASSIGNED 6/26/13 6/26/14 WCSTATU- OTH- AND EMPLOYERS'LIABILITY ANY PROPRIEfORIPARTNEWEXECUTIVE Y� NIA E.L.EACH ACCIDENT $ 500,000 OFFICERMIEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes describe under 0 RIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Renarks Schedule,if more space is regri red) CERTIFICATE HOLDER CANCELLATION ULD AkOFTHEBOVE DE SCR D POLICfE E CANCELLED BEFORE THE EXPIE THERE NOTICE WILL BE DELIVERED IN Town Of Barnstable ACCORDAE POLICY ROVISIONS.AUTHORIZED ©1988-2010 AC R CORPO ON. All rights reserved. ACORD 25(2010/05) The ACORD name nd logo are registered marks of ACORD Phone: Fax: - I: �t t Town of Barnstable *Permit# o Expires 6 months from issue date Regulatory Services Fee ' BMMSTABLF, : Thomas F.Geiler,Director ' ?sass. 9�b %639. .•� Building Division A�en �s Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601" www.town.bamstable.ma.us Office: 508-8624038 Fax: 508-790-6230 'q. EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint VVV Map/parcel Number r e5(J V�Ca— Property Address i CIS W A L N U-T S► IvI A P,,S> 'I C)NA 5, LL C ❑Residential Value of Work 3 Z 0o } Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address YZ 01�C--R Z `rt t L L E R lKS 'WisLNV i S MA STUPl5 iyj►t_LS Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) MV H ❑Workman's Compensation Insurance Check one: APR 1 5 2008 ❑ I am a sole proprietor � I am.the Homeowner TOWN OF BARNSTABLE ] I have Worker's Compensation Insurance Insurance Company Name 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 ❑Re-roof(not stripping. Going over existing layers of roof) . ❑ Re-side. Ll ❑ Replacement Windows/doors/sliders.U-Value (maximum o. '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 re " ;,i:,' `?Z ll ij SIGNATURE: RO"6 e, Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revise020108 The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Amlicant Information Please Print Legibly CNa i6'(Business/Organizationgndividud): 08e2 7- - CAddress: 57 AIARsTONS City/State/Zip: Phone.#: Are you an employer? Check the appropriate box:w- __ Type of project(required): 4" I-am=ageneral-contractor and I 1.❑ I am a employer with � �,.,� �-•• - ^6. ❑New construction employees(full and/or part-time).* have hired the stab-contractors 2.❑ I am a'sole proprietor or partner- Clisted on the attached sheet 7. ❑Remodeling Tliese sub-contractors have g. ❑Demolition • ship and have no employees ..-_, • working for me in any capacity. it,employees and have workers' 9 ❑Building addition [No workers' comp.-insurance z'comp.ir,arrrance,t required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions �3 I am if homeowner doing all work officers have exercised their I I.❑Plumbing repairs or additions G,myselL[No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no - employees. [No workers' 13.❑Other comp,insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'comprnsation policy infomration. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must subrnit anew affidavit indicating such. tr—=Iracton that check this box.must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have mnployees. If the subcontractors have en ployees,they must providt their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to socu a coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine tip to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains•and penalties of perjury that the information provided above is true and correct (Signature: - /ill 6,al f m' r Date: /aB Phone k Official use only. Do not write in this area;tb be completed by city or town officiaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health L Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, i 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-contractors)name(s),address(es)and phone number(s) along with their certificates)of insurance. Limited Liability Compauies*(LLC)or Limited Liability Partnerships(LL.P)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 affidaviL 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 Towa 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 permittlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permittlicense 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 homeowner or citizen is obtaining a license or permit not related to any business or commercial venture (Le.a dog license or permit to born 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 TO. #617-727-4900 ext 4-06 or 1-977-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.gov(dia Town of Barnstable �OpSHE Tp�� . Regulatory Services o% Thomas F.Geiler,Director BARNSTABLE. . MASS. g, �e39 Building Division �lfD t��p Tom Perry,Building Commissioner . 200 Main Street, Hyannis, MA 02601 ' www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION' c Please Print DATE: JOB LOCATION: / 95 klALA/u� ST MARS p0N5 M L C -T number street village "HOMEOWNER': R 06 g K T NJ l !Ic/z y 2 U-(��//3 A/A name home phone# work phone# CURRENT MAILING ADDRESS: (°f5- wlo2sror✓s n��•�ts Mra. 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 fomi/certification for use in your community. I °FtHEr � Town of Barnstable Regulatory Services MASS.�E Thomas F. Geiler,Director i 19. � Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder. as Owner of the subject property hereby authorizeA. to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) i Signature of Owner Date Print Name If Property Owner is applying for permitplease complete the=Homeowners L-icense-' Exemption-Form_:on-the--reverse_side— Town of Barnstable pF tHE rpy_ Regulatory Services Thomas F.Geller,Director + BAMSPABM MAC'1639. Building Division ♦0 Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 PERMIT# 7�f �/ FEE: $ 19 -o�f SHED REGISTRATION 120 square feet or less I q5 W4\ l_NQT 5-1 MARSTC)Ns Mi i LL5 02. G L 4 g 1 Location of shed(address) Village 0667RT M (LLE.R SoF - Li Z 0 04 13 Property owner's name Telephone number T— Size of Shed Map/Parcel# 9 o /1_J94 c /Lem 3 0 1 O Signature Date Hyannis Main Street Waterfront Historic District? 1 " Old King's Highway Historic District Commission jurisdiction? Conservation Commission(signature is 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 REV:121901 � Q J�\ 1 wl 4 le)r, 1 Q u ter.... ,._.g�c �e� Ar♦.fae/e_�Q - MORTGAGE INSPECTION PLAN IT7 ,tre lNSUt�S, ....) 1T1PT TriAT tr?t: BlAl11iNQ4 BHOMM b0 ( M SETBACK REQUIRLi1QlT9.��t �1 1K1 M, OR ARE 09UPY MOM MOLA-nqN UMCOdN'1 ACTIUN UNDER MA'S0. 0.1. MR�T M l LU5 -- n OK'OM 'Vk Ub"OH 7, U► AU OTM�UAM NOtm. MAMCHUSrM __� h:tW 1t111T 1?UC PnOPt)!TY {8 Not LOQATIM IN 1HE ISTABUSHM' Fu= ` "•00MMUNITY PANEL NO.: 250001 OM50 OATS: 8.1g-85 DEED 000F ANY A NOT RIMOM OF D. ANY INDENIURER MAX SUOMMIT TO THE RCOWCD BOOK Cr f/1E tA1T3T OFTp Of RE90AD. ' IEVfJQ axoiN= ARE SHOW! IAW 1MM1 ONE FOOT FROM ThE R PACE -„ FA t;;=- PFiLg9L• SURUL'Y BE YAA6 Tb Vmry TWtW IWCATY UNK IT IS ADIASED CERT. H6. OfYtV' IM4LrAM I1 SAM ON IV E LOCATION W 7URVEY MARiS�A1; USENT A PACFERTY bLR�. V><TtIF1CAT10p OP M%VTI,Y MARlgpes NOT OLAN M. 246 PAM---- V- AOoIftM ONLY B•/ AN AOQ MV. WBTBUMtM1 SUN AY9 AR si CTED P / DA1fb °�1MR'GFICAT►ON TO Be UM FOR MORYOAGt: , -OFFSETS AS 6HOYM ARE NQT TO UWD FOR THE ESTABUS11MENT OF PROPE GIOtJKA9 �^� MAI eras BRADFORD ENGINEERING CO. r _ i=YT- Alk \, ---� . I- , l 7Jy � ` 9401 1 n t►cr �._..gf1iE_I'iA .�an� �� � u It"1 TIri� lr�etlR s, MOPTCACE INSPECTION PLAN QATIF'Y MAY tvC Wll*gS 6NOMM DO ( TO SMACK REQUIRt'.111?IT9 lltuT�, % ARE o y. rwot�t Wcutl" R"CIEMINT ACTION UNDER MASO. 0,�IIII 'A O;iRPT k a)A srbno►I >•, u►asaa oMm� ow �A T►IaVAZ NOT0. MAMCHUSMS MTV" _��w' '1' THAT THI PROPERTY IS Not LODATO IN )HE ESTABUSH u►i FlOpp^Rc ems, OOMMuNttY PANEL NO.: 250001 =50 OATS: 8-3.9-8S - DEED t00 ANY IS NOT RESPCNSIbIX FONT ANY INDENTURFA MAX SUBSEQUMT TO TNT: RgOWgD BOOK 'AM& Or fllS LA'TTST OaD of REOW. EWA AX-3INg A11r SOWN LEW 114M ONE FOOT FROM THE fl PAGE 'AT A N ftCISG SURAy BE MA4E Tb VMIry 54C>,1ZE L CA�TY UNt:IT IS ADVISED CfAT. N10. e MA!M%rA)N It 8Aq0 ON TIC LOCATION W MjRVEY MARISbIC Y A Pr�t*tEAi1f 5UR\�Y. V G'MCATION OR 6UR1'$1'MARklpes NOT pUW BK. '��G'_PACC TIN �....._ ' K ^o=ft*C ONLY BY AOOURAIL WS umi N1 su;I SHOWN, AR ICTED PLANT + - �� AY9 DATKD__,_... 'IF&RVICATION To BE UM FOR MORTGAGE OFFSETS AS SHOWN ARE NOT TO UWD FOR THE ESTABLISHMENT OF PROPS CAOUKAS t^ �' eas BRADFORD .' ENGINEERING CO. PAL ,TAMES W. &DUGIOUKAS R.L4. d8w�9 NA%VHLL XMA.�AJI d 35u5idOL4 39d1IAUA(J blye2:01 L6. SO d3S TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel L3 r�_S - Permit# �[9/ Health Division Date IssVd Conservation Division Fee Tax Collector UPL16ts�c-- i Treasurer �_��TS�c� r Planning Dept. Date Definitive Plan Approved by Planning Board Historic-OKH Preservation/Hyannis Project Street Address Village Owner Address Telephone PLO Permit Request .440 Square feet: 1s floor: existing proposed 2nd floor: existing proposed Total new Valuation � 6 ZoningDistrict Flood Plain Groundwater Overlay Y Construction Type Lot Size Grandfathered: Cl Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family Z o Family ❑ Multi-Family(#units) . Age of Existing Structure Historic House: O Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑Full ❑Crawl Cl Walkout Cl Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half:existing new Number of Bedrooms: existing new Total Room Count(not including baths): existing new First Floor Room Count .Heat Type and Fuel: Cl Gas O 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: 0 existing ❑new size Attached garage:Cl existing 0 new size Shed:0 existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes Cl No If yes,site plan review# Current Use Proposed Use BUILDER INFORMATION Name "' Wphone Number ED C) ;Z Address le License# 61& ��9 S— Home Improvement Contractor# A-�o 4!<5 6 Worker's Compensation# ALL CONSTRUCTI N DEB IS SU ING FROM THIS PROJECT WILL BE TAKEN TO ,�( 424 SIGNATU DATE ' FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION FOUNDATION ' FRAME - - INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL . PLUMBING: ROUGH FINAL GAS: ROUGH FINAL •FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. ' + y OFIKE A 0 - - - - The Town of Barnstable .� • :anxxsrasi.e. • . Regulatory Services Eo►�►+' Thomas F. Geiler, Director Building Division - Ralph Crossen, Building Commissioner 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Fad: 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 building containing atleast one:but-not more.thanfour 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: Estimated Cost c Address of Work: Owner's Name: Date of Application: hereby certify that: Registration is not required for the following reason(s): []Work excluded by law . []Job Under$1,000 []Building not owner-occupied ❑Owner 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 ermit as the agent of the owner: Date/ n or Name Registration No. / OR Date Owner's Name q:forms:Affidav t _ The Commonwealth of Massachusetts a � Department of Industrial Accidents -_ _- Olflce of/m�est/gstions 600 Washington Street -" , Boston,Mass. 02111 Workers' Compensation Insurance Affidavit � r /'��/!/�r�"lr�lllrY '(/%%%%%/% name: location: ci hone# ❑ I am a homeownei performing all work myself. ❑ I am a sole rietor and have no one workin in ca acity =amn employer providing coo ' compensation for my employees working on this job. :: :: men an• X. > ........... : � s. .. a ? ` s ss s?names . X. . `���•:4ii:vv`:"i'•Ji:v i::'•i:�i:i:??::L::L:i•:i;:}}% ri .... .:::. v. >:>.; :>:::>::::>:::>::;::::'::;...::::.....................:..:::•::; .;;:.;:•:; ....... ....... i ❑ I.am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who h3 the following workers' compensation polices: x. co an.,name.» __ E t ESS..::......:................ X. ...:::::::::::::.::::::::::.::::.:::::.::.::...:::.: :::::....:.:.:..:.... ..:::.:::..:.::.:.... ::::::: :::.........:..........::...:. .::::.:.. :...:..:.:::.::::.:::...:::::::...:..:: ..:.:::.:..::::..::::.:>: a ::::::::::::::::7. ::::........................::::.::::::::::::.:.........................................::::::.:::::::::::.::;: ......X. $ . <•:. /{ �i:::.::::::::::.:::•.::::::::.... ........_...:............:::......:::•.....:::::.....;:....:.:..........tea ::::•:::::::::•:::..;;::.:::::.,::::.>'.;::.........:::....................................................... i :.>:c;::>:.:::;::::?:i:•i::::::i;;::�i:�i:�'::::•;:�i;:�>:•::::�i5;::::�i::�::::.;:;:.:i;::k::•:�::�::i:;:�:;a:�::i::+:�i:�i:£::::�i:�:::i5::::�::�i:;�:<::�<:f�::?::Y:::''.::�:::�:%�i:::::is�i:::::::i::�:�:::::;;;;:::::Y:::::S:�i:�:;::;:::::::i:�:;;::::::;• ........................................•:........•:................................:::: .. .. avert± �� ; 2 % +f?`��< :%%%: :':::: :: ' r : : :':::': ;:::: ::::::?:::::::::>:> s: :'>: ::::::::::::::':`i:<; :::s:2?:::;::;;:;:: . 'C SR.n SS: . :: _ 81f8SX. ........;;::;;:•;:•;:: • .....;: <.:.:h •iiii:•i:•i:•isa:i:•i:•ii:i:vi:i•:iii::a:ii:::i'r viii:tiv:yaii:v::i'iiiii::v:'::::.:: ::::::........... ............................. is�:•}}i}iii::?:ia:•i:.i}ii:�:•ii:?i'i::i:i•iiiiiiiiiii:i:::i'^:ti•ii:iii:i:r.:ii}iiiiii:iii:irii_iiii:iiiiiii'i}iii:y}i:;?:Yiiij;:?^}i:!;yyiii:iai::;iiiii:•::;:i'iii :::ii: :ti•i?i}:ii:}ii:;i:•iiiii+:;isisiiii}::::i!isi�::<4iiisv'iiiii?ii::::isii?i::iiiii:i}iiii:<:iJi:rn:?iii:?ii: t!:::+:i}}ii'iiiii:ii?i:iiii:i:i;{+iiiiii::iY:.:is is•::. w:.:�::::::.�:::::•vJii:itia:•i?i:iii:ti:•Ji:•iiiii:!:•ii iiiii.::i:<4ili::•i:.i?:i:::is:ii:4iii::?i:v:^i:ii:i:`i:;i?:;:hi:::?•i:!4:yhi:Ji:i; �Il ... .. ... .... ... Fefiare to secm a coverage as required under Section 25A of MGL 152 can had to the imposition of crtninsl penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to th of Investigations of the DIA for coverage verification. I do hereby c jy under the p ' p alti of perj th he information provided above is irsw and correct ' Signature Date U Z2?--E 7/ Print IT Phone# na J official use only do not write in this area to be completed by city or town official city or town. permit/license# ❑Building Department ❑Licensing Board ❑checkif immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone#; : ❑Other' . 9/95 PJA) Information and Instructions , Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law", an employee is defined as every person in the service of another under any contract of hire, express or implied, oral or written. , An employer is defined as an individual,partnership, association, corporation or other 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 section 25 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,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 i Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation and numbers along with a certificate of incnrance as all affidavits may be supplying company names, address and phone 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. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/limnse number which will be used as a reference-number. The affidavits may be returned,io the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents office 01 Investloadons 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext. 406, 409 or 375 MAY-16-00 TUE 11 :27 EVANS INTERNATIONAL INC FAX NO. 5165962001 P- 02 v)n.�i1nr:NJ^,.e•er:!s.•ri�i!+;11.' i� I. w :•.::°-.15»'<;:•:._:°.r.>: ax be ''.. �dipo. :cJ >.o vraa: ::it..,. .. .u( mr..rtif Fn•r,o A1 ..isa'�e .i� l:. °�_ �. ' >tCis ' . r,'y Rjti�1 .r T�jDATE( h6NVj 05/15/2'6 RD 000F } PHUDureH FAX (516)596-2001 THIS CERTIFICATE 1S ISSUED AS A MATTER OF INFORMATION 'vans International ONLY AND CONFERS No RIQHTs UPON THE CER11FICATE Jr, Pf>_ni nsula Blvd. HOLDER)THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE-POLICIES BELOW. Lynhr oUk, NY '115ti3-2164 COMPAMES AFFORDING COVERAGE • )._................................�•••••.y••_ ......................................... COMPANY Admiral �ns Co Attn: Robert Scide Ext: 104 A ................................................................................................. • _.............................................. IIOsAJ D ...--'Amer1 ca-home .. . 13RG: The Sil-Ray Group, etal. rAMPANY 40 Elmont Road B :._.._........................... ................................. Elmont, NY U003 ' COMPANY RLY ins .................. C i COMPANY D 'y'$, 1. af!'.VKvii• E`.e-�e7._F �,/•r) w�.�,,,,(A:arT�3:sq� e`J�s�ys� C s.. aq�.it.? P:!sfiR!oft' : cu +t�r: c•g,.::.; .:ix,/iF?!yi4. �Ts�r��::i�j,••�-•�,.,.c•..,r.... ,.,,..... ..J.���tL„?Ni'b>ts xOon/Ri�:�o7.dYi'::.)Foi�'N�IEr,.->:.�1v�U&�:r�trl;:t..'t4^.3:.::<L'•"..:L+',`�#T�:v •t`��M�.. f���:f'::,u:7s:4tabd�u.�ii. �.,, .�' y x �mfm:• -� •.A'Le r�wn�'.'R'.'•iC.tX•.Y:'iriF'::.r, CL!!'f•:J.'`.l".;' LL.+:r, ir�'�r?ir�if!1�<'_'s'XS•`. ''T'i°'`.'�i° 'i,leif�'�':4ils:Jb_.:i_:T7;IS I5 TO CERTFY T1z1;TTHE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD 1M13LCAt'kD,NOTWITHSTANDING ANY REWREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS (—L'R71?- ATE fAAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TE;;MS, E)(CLUSICI'JS AND CCNDITIONS OF SUCH POLICIES.LRr9TS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ................................•................................................_...........•........,........................... . ................... f 0 TYPO Or:NBURAWCE POLICY NUMBER :POLICY EFFECTIVE I POLICY EXPIRATION L.rw DATE IMMIDOA-r DATE(MWODfM . U6111'D OL'ciLAL LLAUIUTY i GENER ---AL AOCHI-GATE :S 2,000.00C ... 1:61AMERCIAL 0CFICT'tAL LIABILITY . ........ .. •• PROpUCT6....y.AP/OP AC4 f CLAII M MADE X OC.^UR 1..�.... ....... Aooaco8651 05/14/2000 05/14/2001 :PERSONAL d:ADv INJURY S 1,000,000 OWNL-R'S 6 CON1llACTOKS PN07 i EACNOCCURRENCE Y S........ 1,OOO,OOU. .. FIR6.DAMAGE(Any one nre) E 50 OOr ,.. ----._.....__ _..... i MEDEXP(Anyone peron) 5 Q NJTC440DP_E UADILITY ANY AUTO :COMB6NM, SINGLE LIMB S AL L OWNCO AUTOS .................. :......................:...................... SC.IQDULEDAUTOS .BODILYIWURY ,f (Per oeran) i IIR(D AUr05 ................................ : NON-OWNED AUT09 BODILY f (Par xcidonAonO PROPERTY DAMAGE .I GARAGE UAZILrtV AUTO ONLY-EA AOCIUtNT S ANY AUTO OTWGA TW N AU10 ONLY: . ..... ...; EACH ACrinGNT:S —.•-_,.___.,..,..._ _�. _ E AGGREGATE.S VCL Y.8 UA13 TIY C UMDkL{LA FCRM XL 0252717 c"OCCURRENCE r< 5,000,000 ......EN '. 05/14/2000 05/14/2001 AGGREGATE ... s SJ000,000 .. p ....................... ..................... X^OTHER THAN VW-k4- LA FORM ;S WORKER30WAKWZATICNAND P,LAPLOYIE11VLIABILITY TORYLJAUTS . 2R ':f•'..t:�:•.'r' rti ....... ..................... B 'n,F"kOPRIE 05/14/2000 05/14/2001 :ELer1HA.o`�'oEN7 .s 500,000 x n+cL 500,000 PARINER:IIE�•:C]�JTJVE :EJ.DISEASE-POLICY LIMB ,I ..._...................................................................... OFFCZks AR'c' — —r :ExcL --- EL DISEASE-eA CMPLCYE.:I 500 OOCI uT,Ir�i OF Jf L}t;tlfOhkSIL%:A1'gNSfVWICLW5PEcIAL.ITEMS eneraI Con-tractors tar Home Improvements • rkers Compensation: in NY,GA,CT,MA,NC,NH,PA, & RI f..•r-.-gee-r.•-acs•�„�,araru.,.r,N..r;.-•,...�...r;..;r�r... I •I•"'`.y`'1•"S:l'�'��.::r.:�.fr�....... �i2x7....3r��s.t9:f:�:sv�i`tiS:lYr's:itl+5rri?',�i'•rpv,!"•'_":+.;iyi?...dA ,� -'•^.�`;�•`,ywr.•-p••��••i���`,'�' —.:—s.w. .::.....a....nu.. :..�. -u 1! D•. •'3-S•,;; � e�'::� :. 'u{t, .:d. .....__ 3 ici �u':d'c,..ti,s..ali:.Y.':7�'u-��`.SW1�,..�.o....� iiai -i>�"-I"`.,:.... w• -/•4•:,:,� ..,.:,e!.?S;.h...`r+..r.':K'.+.4rr_,.;I,_:??.A:.::., an.: Y� - �ssr.'.?ce'^•* _ SHOULD ANY OF THE ABOYE DESCRIBED POLICIES BE CANCEI LED MFaRE THE - EXPIRATION DATE THEREOF,THE I NO COMPANY WILL ENDEAVOR TO MAIL 1O FSUC NOTCE T E CERTIfR;ATE HOLDCRNAIiF.O TO THC I F-FT. BRG: The Bil-Ray Group BUTSAILURE uNeT SF(4I.L)Mr.OSEN0ODIJCAT10NORLIABILRY40 Elmont Road DF al{Y KIND COMP ITS 4CCTITS OR RF.PR=ENTATIVES. Flnwnt, NY 11003 AUTH TATNE .r,%:._r•;�.rC.•:,y:•;:TZ;3_�'.�.`:.' :"' ,.y,.;L. kSS (.?[`•;i'.:`_'S;L' -i. L•:::...�^' P. VG�tf.S l'�••• ?. ON '+•tr F-.• --^�.'G..�' T. "; v 4 ._., d'_. ern to ♦ r�. F�•• �'�..i ,a f.• _b'• , a.,.�:X-�.+ki'".y. 3 �fn t �ti .ti:a:s"t 9 Y+..• 1: v,. _!/'_. ./s� .. {i 4 .CM l lC t BOARD OF BUILDING REGULATIONS /�`b����� ® �� ` # a Icense: CONSTRUCTION SUPERVISOR HIGH PERFORMANCE WINDOW & DOOR SYSTEMS Number: CS 067195 I�1.FRC ' A An Arch America Company Birthdate: 08/16/1952 "Equal Sight Line" Expires: 08/16/2001 Tr. no: 6529 x- RestricEed To: 00 Vinyl Double Hung National Fenestration ARGON FILL LOW E PAUL S MACDONAL.D 4111Rating Council 25 MASON RD DUDLEY, MA 01671 e Administrator r Energy savings will depend on your specific climate, house and lifestyle -'pC..'.ye. ♦ ih�� t4 L - -.,. . a..3.. 9 lei f N it i -1f,y'4 ,,,���+++°c��''' y �- ,� --. 1# �. -�•, For more information, call 1-800-782-6347 or visit NFRG's web site at '� l p�� � af5�.'�Tk ii.�.��r�"iyt�`ar`1 :t• b�F`..i�•v�,fank�( i�tSf{. ,.n., ty"Ppa,rtk,fa F`".4�.. 11A.+�•ge r T i {u�t ►• IK�� �4'r�'tff,`�. .,,: www,nfre.org RUN ' .,a 1'K+ � ,� 1 1 #IQ �UII4�ttf�lfiCOlfilfAEt�� <tiVi,�° ,3 �4`py{ Sotar Neat Gain 1fis�te Litt t)�t BCtOr Coefrlpeni ■ Transmittance � A3 ........................................ .......................................... iCsprIuate CO p0raI10;rF 31 Al a 4� F+x,9d T y �" Zn.k.°•Y� � F�+E�f.� za� yiS tl. N 1 ■ sdti Yay,,, 7,1 j`a 'd ,,yf 'L�' ,y.y6,� 2 '{,r j.- nc $pY 'il�F,}a 3n�e�C'r i..r.•agr -3}' ?1 s+. -- k ,"."1 +ti '£� rq'•7M Yll L.:riil`�$ �ViN��S1 rf+f3F 3y �r+ t 14` i ` ,t , , f Marxufacturer stipulates that these ratings conform to applicable NFRC procedures for determining d,' ak *'� tL.:-�.,� yct•s..r r--e1'' Xy y +I- +.�,d•'h 'e . r,�} - I�Ct11D sA r,as fy whale product energy performance.NFRC ratings are determined for a fixed set of environmental *jjr conditions and specific product sizes. s:YF., t ,�Mii�iy,�v.miz ty�>� (II t:u$• x11t;y, T e t`'t�•+ •.r.,.-. ,�L7 tttt� :r .7.::a. ..[.wl...: .x. .:i• .. .1%y,a�Q`('p.N�i:i ,1C�r:'Yf Mw .:'3.A31 ,. ��3�:µi'•. i NEWSUM p�Q(ppE9�AENJS EQ gppiTlON OF A TRIGGER 11t3 � KE DETECTORS Sp.YoU MUST VLW Am" RIATE i A:IOMOffg=94 HA R30DIAT 2ROTOSTSO TzvM v� USFIvov SVAN STAW T► • TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Ma I S Parcel l p 1-�� �, Permit# ��� Health Division go- I'VStALLED I; r Date Issued Conservation Division �1� �� I 'Th V T� IIAN;OFFee 7 Tax Collecto4r �y��IVTgL wiv r at CODE AIV® Treasu Planning Dept. Date Definitive Plan Approved by Planning Board Historic-GOKH Preservation/Hyannis Project Street Address W C-`n u;)� S- Village _ �101 fS"b n S (Y� ( , l Owner WCi(. Y)-Q- m . WCL rG<<r,-1U Q. f, Address l 5 GJ6, n U Telephone t,�)N— U g' Permit Request A D itiOAJw `� � b R6 1"1 � l i/�iACOM Square feet: 1st floor: e 'sting 7bg roposed 2nd floor: existing proposed Total new 3 C19 , Estimated Project Cost� Toning District Flood Plain Groundwater Overlay Construction Type W a 0- F9 41319 Lot Size /Y5 I 16 V/ Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family,ll Two Family ❑ Multi-Family(#units) Age of Existing Structure 0-4,es Historic House: ❑Yes 4No On Old King's Highway: ❑Yes 1 No �,�i� N Basement Type: A Full XCravW ❑Walkout ❑Other 6�O 65 jj Ul� f Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) .411 C✓A/ Number of Baths: Full:existing f new Half: existing new Number of Bedrooms: existing 2 new Total Room Count(not including baths):existing new_� First Floor Room Count Heat Type and Fuel: ❑Gas 0 Oil ❑Electric ❑Other Central Air: ❑Yes ',4 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 // BUILDERR INFORMATION �J Name 1�o G Telephone Number p Address IP,_ �//V U 7' S74, License# MR�s ns /i!( S' 14 Home Improvement Contractor# I Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY PERMIT NO. �••� � - IL DATE ISSUED , - MAP/PARCEL NO. ` 1 1 ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME _ J INSULATION FIREPLACE ' ELECTRICAL: 'ROUGH FINAL _ PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. , . 1 TaWoJLUb(mooed) Pi caipd►a Packages for One sad Tway-Fsu*R=dmtial Batldlap Beamd with Ford Fads MAXIMUM MINI MUM GLvaa9 Glazing Ce7ia8 wall Eloar Baa®mc Slab 8 �'(K) U-vduss lGvalueJ Rrvalaol- tvva Wall paia� Pnkaae 16va m, &valud 5701 to 6500 Heating De4ese Daw Q 12% 0.4o ' 3s 13 19 10 6 Normal !t 12% 032 '30" ' 19 19 -10 6 Noel 129L 0.50 3E 13 19 10 6 B AFUE T 13% 0.36 32 13 2S WA WA Normal U 13% GAG 3E 19 19 10 6 Normal V 130.6 OA4 38 13 25 WA WA iS AFUE ��- W IVA OM 30 19 19 10 6 IS AFUE X IE9'. 032 38 13 2S WA WA Normal Y 12% 0.42 n 19 2S WA WA Normal t IVA 0.42 38 13 19 10 6 90AFEM AA la'!. 650 30 19 19 10 6 90 AFUE !. ADDRESS OF PROPERTY: ev 2. SQUARE FOOTAGE OF ALL EXTERIOR WALLS: 3. SQUARE FOOTAGE OF ALL GLAZING: oZ S"G 4. %GLAZING AREA(#3 DIVIDED BY#2): S. SELECT PACKAGE(Q—AA-see chart above): NOTE: OTHER MORE INVOLVED METHODS OF DETERMINING ENERGY REQUIREMENTS ARE AVAILABLE. ASK US FOR THIS INFORMATION. BUILDING INSPECTOR APPROVAL: YES: NO: q-forms-t980303a i r Footnotes to Table J51.1b: ' Glazing area is the ratio of the area of the glazing assemblies (including sliding-glass doors, skylights" and basement windows if located in walls that enclose conditioned space,but excluding opaque doors)to the4gross wall area,expressed as a percentage.Up to 1%of the total glazing area may be excluded from the U-value requirement For example,3 ft of decorative glass may be excluded from a building design with 300 ft of glazing area. =After January 1, 1999,glazing U-values must be tested and documented by the manufacturer in accordance with the National Fenestration Rating Council (NFRC) test procedure, or taken from Table J1.5.3a. U values are for whole units:center-of-glass U-values cannot be used. The ceiling R values do not assume a raised or oversized truss construction. If the insulation aclrieves the full insulation thickness-over the exterior walls without compression, R-30 insulation may be substituted for R-3 8 insulation and R 38 insulation may be substituted for R-49 insulation. Ceiling R values represent the suin of cavity insulation plus insulating sheathing(if used). For ventilated ceilings, insulating sheathing must be placed,between the conditioned space and the ventilated portion of the roof. Wail R-values represent the sum of the wall cavity insulation plus insulating sheathing Of used). Do nott include exterior siding,structural sheathing,and interior drywall.For example,an R 191equirement could be met ETTfMR by R-19 cavity insulation OR R 13 cavity insulation plus R-6 insulating sheathing. Wall requirements apply to wood-frame or mass(concrete,masonry,log)wall constructions,but do not apply to metal-same construction. . 'The floor requirements apply to floors over unconditioned spaces(such as unconditioned craw6paces,basements, or garages).Floors over outside air must meet the ceilhig requirements. The entire opaque portion of any individual basement wall with an average depth less than 50%below grade must meet the same R value requirement as above-grade walls. Windows and sliding glass doors of conditioned basements must be included with the other glazing. Basement doors must meet the door U-value requirement described in Note b. The R-value requirements:am for unheated slabs.Add an additional R-2 for heated slabs. If the building utilizes electric resistance heating use compliance approach 3,4, or 5. If you plan to install more than one piece of heating equipment or more than one piece of cooling equipment, the equipment with the lowest efficiency must meet or exceed the efficiency required by the selected package. 'For Heating Degree Day requirements of the closest city or town see Table J52.1 a ROTES: a)Glazing area and U-values are maximum acceptable levels.Insulation R-values are minimum acceptable levels._ R-value requirements are for insulation only and do not include structural components. b)Opaque doors in the building envelope must have a U-value no greater than 035. Door U-values must be tested and documented by the manufacturer in accordance with the NFRC test procedure or taken from the door U-value- in Table J1.5.3b. If a door contains glass and an aggregate U-value rating for that door is not available, include the glass area of the door with your windows and use the opaque door U-value to determine compliance of the door. One door may be excluded from this requirement(i.e.,may have a U-value greater than 035). c)If a ceiling,wail,floor,basement wall,slab-edge,or crawl space wall component includes two or more area,with different insulation levels,the component complies if the area-weighted average R value.is greater than or equal to the R-value requirement for that component. Glazing or door components comply if the area-weighted average U- value of all windows or doors is less than or equal to the U-value requirement(0.35 for doors). 43 I Q i _. . -PROP'5.f-D �x 15�1/v� �ROPbSrj t J' oZ x RA RSA VF-A'7 - R� �--- k_ 3 0 LaxEl R All 10 /06n .fib/S�S AIVCAOR5 g L` D�G�Z�' ,� iN /( Y c A/ The Town of Barnstable WE' .° Department of Health Safety and Environmental Services Building Division NAM 367 Main Street,Hyannis MA 02601. aswss. ibsq. `0� Office: 508-8624038 Ralph Crossett Fax: 508-790-6230 Building Commissioner F HOMEOWNER LICENSE EXEMPTION �( a Please Print DATE: �"— V � ` JOB LOCATION: l Ct�l h U S�, Q CS 4(i Y1 S V I f l IS number stre t village -I d 8�l�-1 � 4� V° S"HOMEOWNER": W �- 1 I 1 w\1•0Ct�C� ' �. 7-4 f name home phone# work phone# CURRENT MAILING ADDRESS: o C u✓L� 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 su eft rvisor. 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 buildingjermit. (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. ° AA1_ i a� Signature df'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 Concoction 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 to amend and adopt such a form/certification for use in your community. i Q:FORMS:EXEWT ! The Town of Barnstable Department of Health Safety and Environmental Services Building Division Y 1 367 Main Street,Hyannis MA 02601 Office: 508-8624038 Ralph Crossen Fax: 508-790-6230 Building'Commissioner i Permit no. Date AFFIDAVIT 1 HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION 1 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 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 exceptions,along with other requirements. Type of Work: Estimated Cost r Address of Work: ICA W Cul�1\ -mil I ► ICI:r5+o i'1 � OQ Owner's Name: Date of Application: 'F'715 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 mowner 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 as the agent of the owner. Date Contractor Name Registration No. OR Date Owner's Name q:forms:Affidav ��� ��� �� i t /, / ` � �����e�/����� ,3 ��_ i � �� ���� �� The Commonwealth of Massachusetts Department of Industrial Accidents `' _ _ Office ofinyestigzaaffs �' 600 Washington Street Boston,Mass. 02111 jork/% C% sarion Insurance %avit �titt�ica1ncW' Irllra tzt�rc.�;�0//%%%%/,%%// � / r/,�"/,• ,,,,,,,,, ,/// � �, , name: UA 1n-� location: " `-15 city TmLrs+DnS i ' Im � d V Z 0 � � phone ❑ I am a homeowner performing all work myself. ❑ 1 am a sole ror)rietor and have no one working in any ca acity ❑ I am an employer providing workers' compensation for my employees working on this job. compnnv name: address: city. phone# insurance co. Pn11cV# I am a sole proprietor, general contractor, homeowner •ircle one)and have hired the contractors listed below who have the follo«ing.workers' compensation polices: companv name: address: city phone M msornnce co. oircv#.. :;.:..::....:: /iiiiaiaiiiiii / %�///MMMM; r—ovn.cl��i C49 camnanv name: address: cih^ phone M :.::::....::... .....;::::.. insurance co. oiii v Failure to secure coverage as required under Section 15A of MGL 152 can lead to the imposition of criminal penalties of a tine up to 51.500.00 and/or one yeah'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herebv certify under the pains and penalties of perjury that the information provided above is true and correct Signature Date _ Print name Phone# official use only do not write in this area to be completed by city or town official city or town: permit/llcense 0 ❑Building Department ❑Licensing Board ❑check if immediate response is required ❑Selectmen's Office ❑health Department contact person: phone#; ❑Other (trvuea 9/95 PJA) r' r� Information and Instructions -= Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", an employee is defined as every person in the service of another under any coutr.:�. of hire, express or implied, oral or written. .N, 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 receive: c: 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 section 25 also states that every state or local licensing agency shall withhold the issuance or renew: of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who.hasl--� not produced acceptable evidence of compliance with the insurance coverage required. Additionally, neither.the•.'. commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. . i Applicants . Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company-names, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and '.date the 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. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be retuned io the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a call. VIA The Department's address, telephone and fax number. The Commonwealth. Of Massachusetts Department of Industrial Accidents amce of Imlesduadoas . 600 Washington Street Boston; Ma. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375