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0549 WHISTLEBERRY DRIVE
Dr e 96 Town of Barnstable *Permit# 6ssowtis jr+aee trW dare $ Regulatory Services Fee NAM Richard V ScW4 Interim Director Building Division Tom Perry,CBO,BWftg Commissioner 200 Main.Stream Hyannis,MA 02601 'N www.town.batnstable.ma us Office: 508-862-4038 Fax: 508490-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL. ONLY Not valid wMew Red Mlrm Imp" Mtp/pafcd Number Di a PropertyAddress "I 1)l)�1 S�I.K.Lr fif Q ❑Residential value of work$ a� A+�nm fee of SXU0 fofwork Feder S6000.00 Owner's Name 8t Address n yVleh , V�h1 s p I �ru ,l .m el0-U J -A � t�cSor✓ Contractor's Name ��1� s Telephone Number qPI-2 7,k Nome Improvemmnt ConftcWr License#(if applicable) l 7,3 J Email: construction Supervisor's License#(if applicable) �7 gZW 'sC;ompensation Insurance Check AUG - 7 2014 ❑ I am a sole proprietor I am the Homeowner I lave Worker's Compensation Insurance i Insurance Company Name TOWN OF�ARNSTA�LE Workman•s Camp.Policy# Cepy of Insurance Com Certificate mast accompany each permit. Permit Reggest(check box) ❑ Re-roof(burrimne nailed)(stripping old shingles) All construchOn debris will be taken W ❑Re-roof(hurricane nailed)(not stripping. Going over emstmg layers of roof) ❑ Pie-side Rerlac^emeut Windows/doardsliders.U-Value , 3 (maximum.35)#of ws 3 #of doors: ❑ SmokelCarbon Monoxide detectors 4 Door plans marked with red S and inspections required. Sqxarate Electrical dt hire Permits required. *whew nqnre& Immme of eris pemit does not cmipt comPlmw wilt►other town dgmrWMMt rgpd trans.i.e.xiskw,Cam,etc. ***Note: Property Owner must sign Property Owner Letter OfPermisaion. A of the Home Improvement Contractors License 8c Censftcdw Supervisors Liceaae is r SIGNATURE: T-.VMVDd V0W1difl9 Cb08NXMMUM PE0&TWMtES&d0c Revised 061313 a Southern New England Windows d:b.a Renewal by Andersen of SNE Massachusetts -Department of Public Safety Board of Building Regulations and Standards CLlnstruition Superi-Nor License:.CS_M707 BRIAN D.9DEINMSON 7 LAMBS POND CIRCLE Chariton MA 01507 %9 Expiration Commissioner 09/0812014 r?�C%G�crJ3clr�l�u-;rl7a e Office of Consumer A airs d Business regulation 10 Park Plaza-Suite 5170 Boston,Massachusetts 02116 Home Improvement Contractor Registration RegisfiW on: 173245 TVW SuPP*Merd card SOUTHERN NEW ENGLAND WINDOWS LL DENNISON BRIAN 1137 PARK EAST DRIVE WOONSOCKET,RI 02895 — Update Addr and retare nrd.Mark reawn fir dance. Address 7 Rmawai i Employmaut L..I Lori Card Wi_�g^,,,, of Coma�er AIBln Q Ombeu RgaYlioa Lkeaae or rnkttatku roW fhr ktdivWW at only ���M' E OpRoveffi NT CONTRACTOR Eefot•the eaplratiah data If(hood rmm to: �� OLBu of[etnnmcr Affaka avd Hotism RegWatiha w'- 'Rapbtratlae:173245 Type. '10*park Flom-Suit e'5170 F:-S' Eapiratlhrc gt9=4 Suppiement:wd B9904MA 02116 SOUTHERN NEW ENGLANO WINDOWS LLC,. RENEWAL BY ANDERSON DENNISON BRIAN t 1137 PARK EAST DRIVE WOONSOCKET.Rt WM Uaderaerntary Not•a0d wil6om aitlea .f The C'oMmonweatth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 92111 www massgov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/PIumbers Alipficant Information Please Print Legibly S Name(Business/Organization/Inaivianal)- 1-94 a Address: b Jost! O City/State/Zip: I-/All-Q/A/ I . . 't�84, Phone#: ©/ m?a $- �Voo Are you an employer?Check the appropriate boa: Type of project(required): 1. I am a employer with A O 4. ❑ I am a general contractor and I employees(full and/orp&t-time)* have hired the sub-contractors- 6. ❑New construction 2.❑ 1 am a sole proprietor or partner-, listed on the attached sheet T. E]Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity, employees and have workers' t 9. ❑Building addition [No workers'comp.insurance comp.insurance. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am ahomeownerdoing all work officers have exercised their It.❑Pktmbing repairs or additions myself.[No workers'comp- right of exemption per MGL- 12.❑Roof repairs insurance required.]t C.i 52,§1(4),and we have no employees.[No workers' 13.9,Other t.() comp.insurance required.] 'Arry applicant that chedks box 91 must also fill out the section below showing their workers'tompawdo I policy information. t Homeowners who submit this affidavit indicating they am doing all work and then hire outside contractors mustsubmit a new affidavit indicating such_ *Contractors that d=k this be>x must MOW to additional sheet showing the name of the subcontractors and statswhethes or nDt those entities have employees. If the sub-corttracM have employees,ow mint provide theme worker'comp Policy uumbe r I am an employer that is providing workers'compensation insurance for my employees: Below is the policy and job site information, Insurance Company Name: StJr C 1zA1v Policy#or Self-ins-Lic.# �a 3 Expiration Bate Job Site Address: City/State/Zip: Yl M I Ii L 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 ofthis statement may beforwarded to the Office of Investiaations of the DIA for insurance coverage verification I do lwreby ' under the pains and penalties of perjury that the informragon provided above is a correct c Signature: Date: ? 'hone# Official use only. Do not write in this area,to be compIded by arty or town official City or Town: Permit/License# Issuing Authority(circle one): !.Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.-Plumbing Inspector 6.Other Contact Person: Phone#• Client#:30124 SOUTNEW ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MMDNYYY) 8/06/2013 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 corHflcate harder Is ert ADDITIONAL INSURED,the policy(lee)ins:=t bs_rdorssd:If SUBROGATION IS WAIVED,sub4a t to the terns 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 endomement(s). PRODUCER WjACT Anita Little Willis of New Jersey,Inc. PHONE :856 914-4660 No:856-914-1881 1015 Briggs Road,PO Box 5005 , x, Mount anita.little@willls.com Box 5005 INau AFFORDING COVERAGE NAIc s L!ovr:t Las:rsl,NJ 0805d• pw•-V�A..SeleCtWe Insurance Co of the S 39926 INSUREo INSURER B:Argonaut Insurance Co. 19801 Southern New England Windows LLC INSURER c:Beacon Mutual Ins.Co. 24017 D/B/A Renewal by Andersen 26 Albion Road INSURER°' Lincoln,RI 02865 INSURER E: WSURER'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 CONTRACTOR 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. LTRR ADDL TYPE OF INSURANCE U POLICY NUMBER POLD YY IIIM/DRM LIMITS A GENERAL LIABILITY 5202945900 0811012013 0811012014 EACH OCCURRENCE s 1 000 000 XAL GENERAL LIABILITY $100 000 CLAIMS-MADE i�OCCUR 1 MED EXP --ne pin) $1 C 000 PERSONAL a ADV INJURY $1 000 000 GENERAL AGGREGATE s3 000,000 GENT AGGREGATE LIMIT APPUEs PER: PRODUCTS-COMPmP AGG s3,000,000 PROPOLICYJEC LOC 9 $ A AUTOMOBILE LIABILITY S202945900 8/10/2013 08110=14 COMBINE SINGLE LIMIT.Mascd 1,000,048 X ANYAUFO BODILY INJURY(Per person) i ALL OWNED SCHEDULED AUTOS AUTOS BODILY IIN lUFiY(Per arrldwrt) i X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE s AUTOS acdderd a A X UMBRELLA UAB OCCUR S202945900 D811=013 0811012014 EACH OCCURRENCE $5 000 000 EXCESS IJAS HCLAMS-MADE AGGREGATE $5 000 000 DO RETENTION $ C woar Cta1PElNSATION 0020-R! "a121/ru13 01=112014 X ,WAT1L 1 OTH 1 AI:D EMPLOYOW LiABOXY B ANY PROPRIE1MPEARTrI YIN AIC927818352394 8/2112013 08/21/201 E.L.EACH ACCIDENT $1 000 000 OFRCERIAAEMBER IXCLUDED? i� N!A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $1 00)000 es,ay desafs under DESCRIPTION OF OPERATIONS bebw E.L.DISEASE-POLICY LIMIT 10,000,000 DePrPT O!!.^f OPE�ATIO!!S!L^CATXlNB f:r SfS i E8(Aio ACORD tCt,A.X�.lf.o.�a3 R3.—.-. SadiCe 77:dlTi ipiei ii PoyiilPid) CERTIFICATE HOLDER CANCELLATION Southern NE LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 26 Albion Road ACCORDANCE WITH THE POLICY PROVISIONS. Lincoln,RI '02865 AUTHORIZED REPRESENTATIVE • iL. a!Imm i ®1988-2010 ACORO CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD nO'.r e."nae•enee •v, Renewal b!'Aflde1e1. - RENEWAL AY ANDERSENcWL% Sao? near ateuarvn . NWMAS 26 Albian Road • Lincoln,Ri 0280 Langan 91257 Yhooe S6fi M5 22SS•Fax 401.633.6602 rOi&qflTAX V040- aOMD 5oad—New Eeo,wd NSadowy LLC d/b/a Renewal by Andemen of Southern New—gl-nd rt CUSTOM WINDOWAND DOOR REMODELING AGREEMENT SeermAdlnecS Q+Pscra Tp c;&&IPA), v IL` ,rrlretrnr ng!�:AO Ob Bu�'ar(s)hca j:A-ir l y wed mallY 291en to pundhase the products and/or services of Southern New England Windows,LLC d/b/a Renewal by Andcraan or Sout6crn.Newer En,giatrd C40ontractoe),in nocordanoe with the tmm an rimer detmbed on the from and the merse or this agr_retnent and on ncc attachod spce fien6on sheet{s}(coElecovely,il' " ) O Hlstodc (]Condo HQA4 0 TotalJcbArVw �Tft(Are: Medad of pcyment: 0 CheEk O Ctrh &KUKed ' — wQe�Cs Igmk U11 .22 Credit Cards are accepted for dcpvalt orb-rrtttEtrtaro l/3 of the Brlathee it Snit ofiob €nansto0 Gatnpletfah Oatc proo t axt(I m see Credb Caad lbyrnoN Fumy By fVV%this Balance t 3��/ �>aeeI, � tobUnwtbertd�the� of� �p � ice and must retiot made by odor l d nrr,ot be madetack r ask be bypsrsoeal cltedc lank tirade w mot► Boyor(s)agrees clod andemusails that this Agreement canstytuove the oaths,understanding beew,eea the pastles,and that there a"ao herbal uaderstandiage changing—Y of the terms of this Apeeme.L Bayer's)Willmowledges that Bayer's) (1)has road ads Agreement,aaderahsn&rho terms of we Agreement,and bar received It ooerPleted,a gpcd,and dated eopy of this Agreement,including the two attached Notices of Cancellation,oa the time firstwtrittes above and(2)was may informed of Bayer'sArbsto cancel thisAgnmumat.r)OKnTSICW PH19COMIStACTIFTFU=AREANTRLtNk6pACW. (fads/turd Salta 0*)Notice to Ruyers(1)Do am sign this Agreement if any of the spaces d for The agreed terms to the extent of then available inl6nnsAoo are left blank.(2)Yon are eati aed to a copy of this Agreement at the time you sign 1&(3)you may at any time pay off dhe fan unpaid balance doe under this Agmemeat,and in so doing you may be enagdod to receive a partial rebate of the!nano and insurance chatgm(4)The seller has no right to anlawfolly enter your premises or 60811ntit any breach of the peace to rtptteSees goods purebased under thine Agreement.(5)Yea may cancel d"Agreement if it has not been signed at the main office or a branch office of the seamy provided you notify the eager at his or her main office or branch office shown in the Agreement by registered or certified arid,which shall be posted not later than of rho third calendar day after the day on which Ute buyer signs the Agreement,—cledisg Sanday and any holiday on which regular mauli deliveries am not load*.See the accompanying notlioe of eaneeU&eW=form four an eYPlaaat' buyer's rights. buyet�s the consumer edwatiun materiels pmvWW by die Rhode island C6ntracton Regssawtion Board �(8egrr?IidaalsJ gy++ an of Southern N w Fmgland ) Buya{s) B r gr tan Of n 11 (! � .S7gryrtn� Print Name or Psodact l4wgrger P nt Name Print Ifaree YOU, TILE BUYEA(S), MAY CANCEL THIS TRAM ON AT ANY 7 M$PRIOR TO MiDXIGLiT OF THE THIRD BUSINESS DAY AFTER THE DATE OF TIOS TRAN&A TION.SF.S THE ATTACKED NOTICE OF CAN CELLMON taORMS 1FORAN W[PIANATTON OF TWS IUGHT. Sic-....- - - - - - - K- - - _sc F LATION NOTICE OF*ANC_iELLATION Date of Tiwtsacdon You — — �� tmrtasl I Data of Tranwt don Yau may cancel this transaction,without ae►y penalty or obligation.within I this transaction.without any ponaky or obligation,within three business;i s from the above date.if you tancd,arty three businm days from the above daft.If you cancel,any property traded in,any payments made by you under the property traded in,any payments made by you under the Contract or Sale.and any negotiable instntrnent cxttcuted I Contract or Sale,and any negotiable ins&ummst executed by you will be returned within ten business days following I by you will be returned witisin ten business days following receipt by the Seller of your cancellation notLce,and arty I reeelpt by the Seller of your cancellation naiice,and any Security interest arising out of the transaction will be security interest arising out of the tarsaction will be canceled.ifyou cancel you must nuke availablo to the Seller l canceled Ifyou cancel.you mast make available to the"jer at your residence,in substantially as good condition as whet+ I at your residence,in substantially as good condition as when re4ce3ved,any goods delivered to you under this Contract or t revived,any goods delivered to you tamer this Contract or Sale;or you may.if you wish,comply with the instructions of I Sal%or you may,if you wish,00mply with the instructions of the Seller regarding the return shipment of the goods at the the Seller regarding the return shipment of the roods at the Seller%experme and risk.if you do m2ke the goods available � Seller's expense and risk.If you do make the goods mailable 0o arise Seller and the Seller does not pick them up within too Cho Seller and the Seller does not pick them up within twenty days of the date of tancelladort,you may retain or I twenty days of the date of tanoeltation,you may mWn or dispose of the goods without any further obligation.If you 1 dispose of the goods without any further obligation,if you fail to make the goods available to the Seller,or if you agree I fail to rake the goods availilabla to the Seller,or if you agree to return the goods to the Seller and fail to do so,then you I to return the goads to the Seiler and UR to do so,then you remain liable for performance of ail obligations under the retndn liable for peefornunce of all obligations under the Contract.To cancel this taw=ction,mail or deliver a signed I Cortxwt.To canal this transaction.mail or ddiver a signed and dated copy of this cancellation no' or oth er l and dated copy of this tnedlation notice or any other written notice,or send atol to Ren An n of I written notice,or send a m telegra to Renewal byAndersen of Southern New England at 26 Albion Road, I S. 1 Southern Now England at 26 Albion Road,Uncoln.R10286S, NOT LATER THAN MIDNIGHT OF ! NOT LATER THAN MIDNIGHT OF (Date) - 1 HEREBY CANCELTHISTRANSACTION. ! 1 HEREBY CANCELTHISTRANSACTION. luruM • Mee case. Dace �. �is+°1r fltreatrr. ewe Msrer - pyy. RDR Ct-Wino Wyer Gopy:Ycttaw Buller Cop.Fink 110 Town of Barnstable *Per #� 3 a y Expires 6 months from issue date Regulatory Services Fee 13 s • anarrsxnaU& KAM B Thomas F.Geiler,Director X-PRESS PERMIT Building Division Tom Perry,CBO, Building Commissioner JUN 2 4 2013 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 TOWN GFRO4BLE . EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY �jV`, Not Valid without Red X-Press Imprint �V" l Map/parcel Number 6 6 / ��� } � Property Address ��TLf.3£�,Q,�cUVI,—�ssAoY1S 1 \11��� K 0%oyl Residential Value of(Work$y3 c Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address ,` �F, .i,. C,�� 1 W o`Sln4 545 W► Ni.SzrL�as�x>!0.w�rwe. Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Email: Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate roust accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side Replacement Windows/doors sliders. -Value (maximum.35)#of windows #of doors: ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *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&Construction Supervisors License is required. Q l SIGNATURE: C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\8R76BDVA\EXPRESS.doc Revised 061313 I ENE Town of Barnstable B,exsre.ts Regulatory Services PAAM 1639, Thomas F.Geiler,Director Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION i ^101 Please Print DATE: d dl 41 JOB LOCATION: 5,441 'number street t 4—► village "HOMEOWNER":,oft\_ ��CI7��O S %w) name home phone# work phone# CURRENT MAILING ADDRESS: gtwn-4. C4 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. �>wtkA Signature of Home ner 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. C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\8R76BDVA\EXPRESS.doc Revised 061313 The Conrnrontvealth of Massachusetts , Department of Industrial Accidents Office of Investigations 91- 600 Washington Street Boston,MA 02111 tp{vist mass.govIdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Busmeess/0iganizationlindividw1)_ ule„/ln�WA." Address: 5q!����� t.�Jf3E�ILQ�L�ttT,� City/State/Zip: one#: Are you an employer?Check the appropriate box: T of project 4. I am a general contractor and I 3'Pe p J (��� 1.❑ I am a employer with ❑ 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 g_ ❑Demolition worldrig for me in °ffiP- capacity. employees and have wo�dcers' [No warrens'camp.;*insurancec � ty insvrance.I 9. ❑Building addition 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 I LEJ Plumbing repairs or additions myself o workers'• right of exemption per MGL repairs anrnn� -1 s c. 152,§1(4) and we have no 12-❑Roof employees.[No workers' 13.❑Other comp.insurance required] *Any applicant that checks boa#1 must also fill out the section below showing their workers'compensation policy infmmatimL 1 Homeowners who submit this affidavit indicating they are doing all wad and then hire outside contractors dttn;.submit a new affidavit indicating such. kantractors that check this box must attached an additional sheet showing the name of the sub-coutractnrs and state whether or not those entities have employees. If the snbcaauactcis have employees,they mast provide their workers'comp.policy number. I am an employer thatis providing workers'couipensation insurance for my enTWem Belotw is thepolicy mid job site information. Insurance Company Name: Policy#or Self-ins.Uc.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerrd&under �the ^pains ,a1nd pwralties ofperjary that the information provided above is true and correct Signature: LX1J a M 1 Y\.W ^ Date: Phone#: L O 1_Q� f"`C Official use only. Do not write in this area,to be completed by city or town official City or Town: PermitUcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/rown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: - 6 moo•„�>.� TOWN OF BARNSTABLE Permit No. --_25956�._._-.-.. Building Inspector 7aaTa.n. Cash --------____-- � rua g'to r�+► Bond -'- OCCUPANCY PERMIT --- - - ---- Issued to Bayside Bu RIbIq CO. Address, -� 549. RAstle a ry Drive, l r"tm- "i Wiring Inspector / ( i Y .Y. _ Inspection date Plumbing Inspector ' L t - Inspection date Gas Inspector Inspection date Engineering Department Inspection date Board of Health ` -,a: .-f Inspection date THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE BUILDING CODE. ...................................t.............. , 1s......�.. ....s............... ...... ....... ......................_............................... Buildin.- Inspector FROM z• TOWN OF BARNSTABLE BUILDING DEPARTMENT i MR. FRANC I S LAHTE I NE A# .'._". .i,. < 4....9 307.,MAIN STREET HYANNIS, MA" 02WI TOWN CLERK Pho4e775-1120 SUBJECT: FOLD HERE• • ' DATE ., MARcm 98 - . MESSAGE . �av *+am�`.#�'r er.a.� rY . ,C WORK HAS" BEEN COMPLETED UNDER RP„�Rmi- .# 59.56 �(BA -$LDG� •CO�).,. j PLEASE "RE'L'EABE 'RGNIJ "' C, SIGNED DATE i REPLY • - ' " - SIGNED N87•RMI • - RECIPIENT: RETAIN WHITE COPY,RETURN PINK COPY- • s' +. PRINTED IN U.S.A. SENDER: SNAP OUT YELLOW COPY ONLY.SEND WHITE AND PINK COPIES WITH CARBON INTACT. A r' ma and I number ol tup 6( $ ct✓Q •:L sVsso s p of nu be .................................. r �W�/ �FTNETO� t Sewage Permit number Z BASd9TAB E, i House number ............. �5 11"t r~tt� ..... ' rasa L wryt��.�.r..... ....ry..aa�� INI•�•:pv«.�,_.., .. Apo,t639• ♦� r „1f 'FOYPYp� '� ! 38TOWN�. �OF BARNSTABLE BUILDING INSPECTOR rr APPLICATION FOR PERMIT TO S N TYPE OF CONSTRUCTION .....lM oo. }-4Z! l'1 .......................... t .................................. � -.......................1 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: ,�/� 1 Location .......:.,C.� hZ ..T.. . .j>J. ... ................. .'......zf�. �^'. ........!.n.X.1..IS........................... ProposedUse ......RS.7.!.Ae-yL4 .,C......................................... ....................................................................................... Zoning District ..........R..,F...................................................Fire District ..........4" .' 5.....:V."...`.1.�.1 ........C,�"��'. ds� Nameof Owner ........R. /.`�.�.�C:......................................Address ................. .................................................... Name-of Builder ....... ..�:�/..�.!.I*,,>..4re...................................Address ..................e: ................................................. Name of Architect .......$..s... s....... .(?......`.�.e................Address .................0�........................................................ Number of Rooms .........42_....................................................Foundation ......... .. Exterior ........ ..........C 1: t !47.0 .................Roofing ................(.1s1P. .......................................... L'f- �Y .Interior � - �S.S.F4�►�.......................Floors ........ W...........-....�..1...... .. ........................... ............... ....................�.�.�. . Heating .......G-..H..A.......�r��...................................Plumbing .................2.....d�r�ttr�s � -'��� Firepp I' Ck / Approximate Cost G.a �� ,,,,,,,,, lace ..............° ..............;.i........ .tl.s:?. .K.................... y.............. ................. .Definitive Plan Approved by Planning Board ------------_--_--_-__ f•. ------�9-------. Area .....��..,9.�..... ............... Diagram of Lot and Building with Dimensions Fee ............. ........................... SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ... ..1 ........ ................................. Construction Supervisor's License .... ......... t . •BAYSIDE BUILDING CO. No, 25956 permit for •• One Story Single Family Dwelling ............................................................................... Location ..Lot 72........549. . ....Whistleberry. . . . Dr. . .. .. . ....... ....... .... .. ... Marstons Mills ............................................................................... Owner .B ... ayside Building. . . . . ...Co.................. .. .... .. .... .. .. .... Type of Construction ....Frame Plot ............................ Lot ................................ F Permit Granted ......January 10, 19 84 Date of Inspection 19 e • . Date Completed .. :7Z.F'�1�......19 r � TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 0 o•/ Parcel Cyr Permit# �{ —d'Z 0 Health Division �3-��27/�L g�23 - � Date Issued 3 2 Conservation Division 8 3 00 Fee, a�'S 2 Tax Collector � SEPTIC SYSTF UST,BE Treasurer i66) INSTALLED IN COMPLIANCE Planning Dept. WITH TITLE 5 ENVIRO►��� IMTAL COPE AND Date Definitive Plan Approved by Planning Board °TOV . 'GULA•TIONS Historic-OKH Preservation/Hyannis ! Project Street Address LJ h// nS`-.r4 s?e 19,q / q/i,5 7 2 Village ��' 7 'l11�g �✓t;l 1 S { Owner i h -47.9 f� .�E- /,�n G Address —11 S Cy rti t_14Z&ee$2 > 12. Telephone g� 3797 Permit Request - 44 r Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new Valuation !Un® Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size 413 Y&V Grandfatfiered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family X Two Family ❑ Multi-Family(#units) Age of Existing Structure fug' Historic House: ❑Yes R No On Old King's Highway: ❑Yes No Basement Type: W Full ❑Crawl , AWalkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half:existing new Number of Bedrooms: existing new Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑ Electric ❑Other Cpntral Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes h No If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION Name l Telephone Number '0—D 7 yb— Address License# C Home Improvement ContractorX Worker's Compensation# ' ALL CONSTRUCTION DEBRIS RESULTINGFROM THIS PROJECT WILL BE TAKEN TO QJV 5i;�p SIGNATURE DATE FOR OFFICIAL USE ONLY 4 ` PERMIT NO. DATE ISSUED MAP/PARCEL NO. t' ✓ _ - , r ADDRESS OWNER ^' � •• n `j � .t _ • ' DATE OF INSPECTION: r, FOUNDATION FRAME INSULATION FIREPLACE - t � ELECTRICAL: ROUGH .. . FINAL - PLUMBING: ROUGH 3 FINAL t - GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN OF THE T N�. °`'tio� Department of Health Safety and Environmental Services Building Division =' BARNSfABM = 367 Main Street,Hyannis MA 02601 HAss aTEo 59. MAC 1. Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner HOMEOWNER LICENSE EXEMPTION (' Please Print DATE: Q —o7—3 JOB LOCATION: I S G e° GL S " l S �� number Surd �7 q, village / ..HOMEOWNER",/,-Md-Cc /� h�IJ(Ql"I� 7�e? 3 / 7 / name home phone# work phone# CURRENT MAILING ADDRESS: ���q I�/h 1 1S41e e_,f r r Plar5-{nS Yj1I /1S M/-� city/town / state rip 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. Sign cure of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,06b 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 petsons. In this case.our Board cannot proceed against the uniiccnsed 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. 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Y::h}fivjY.33:.x::::� ��%.11j//,f to S1300.00 and/or P;ATJJtmder 6eetlon ZSA of MGL 1SZ an lesd to the ftRwidmof eslatioal peaaities of a Sae trp Failnre to secure coverage req is dhe form of a STOP WORK ORDH.R and a f bM of S100.00 a day against Mr- one ttt d that a one years'imprisomnent as wen as eitvll penalties otthe DIA for coverage verincadm copy of this statement any be forwarded to the OIDee of Invesligatitms o that the information provided above it true and correct - �I do hereby certify under the puma and pertaTties f pt�ury -- d O n>�e 02 3 _ . Sitmatwc Print name h d Phone# I oMcbd town. ofnCiai we only do not writs in this am to be eomplsted by city or Department pe�t/ucense0 ❑Bunding P city or town: QLic,=wg Board ❑selecanen's Office ❑check if immediate response is required ❑Health Department phone — ❑Other contact person: (A.Awa 05 P1A) Information and Instructions ;'\1 assachuserts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for the quoted from the "law", an employee is defined as every Person in the service of another under and• ccz employees. As q of hire, express or implied, oral or'written. An employer is defined as an individual, partnership, association, corporation orother es of a deceased employer, wo or the nor:the foregoing engaged in a joint enterprise, and including the legal repentity, es to employees. However the owner of a trustee of an individual,partnership, association or other legal entity, employing emp Y not more than three a artments and who resides therein, or the occupant of the dwelling house 7 dwelling house having P another who emplovs persons to do maintenance , consmiction or repair work on such dwelling house or on the groan` building appurtenant thereto shall not because of such employment be deemed to be as employer. iv1GL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or�ree new applicant of a Iicense or permit to operate a business or to construct buildings in the commonwealth for any pp c not produced acceptable evidence of compliance with the insurance coverage required. Additionally, neither the commonwealth nor any of its political subdivisions shall.eater into any contract for the performance d public work z- acceptable evidence of compliance with the insurance rcquir� of this r have been presented to the cones: _= authority. - - ...... . 121 Applicants Please fill in the workers' compensation affidavit comlileiely,by checking the box that applies to your situation and supplying company names,address and phone numbers along with a certificate of insuuance as all affidavits maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and or town that the application for the permit or lic�se is date the affidavit. The affidavit should be reamed to the�3' questions regarding the 'Uw" or if being requested, not the Department of Industrial Accidents. Should�ym have mY are required to obtain a workers' compe nsation policy,please call the Department at the mmber•Iisted below. City or Towns 'The Department has provided a space at the bottom o:+��e Please be sure that the affidavit is complete and prin linwtigatiow has ted Iegi�bly. to contact Ym regarding the applicant. Please affidavit for you to fill out in the event the Office of �. . ie �vits�y be returned TO be sure to fill in the permitnicease number which will be used as a reference the Department by mail or FAX unless other arrangements have bees made. cooperation and should you have any questions. The Office of Investigations would Irke to thank you in advance for you coop please do not hesitate to give us a call. The Deparunent's address,telephone and fax member: The Commonwealth Of Massachusetts Department of Industrial Accidents Me of IpyestlgatlollS '600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone #: (617) 7274900 .eat. 4069 409 or 375 FILE # D7919 CENSUS TRACT # pAGE aol DEED BOOK 37aa pAGE LO CLIENT ': John F Meade Es p A OK OWNER : Earnest J Linda R LeBlanc ASSESSORS PLAN PLOT APPL I CANT : same M 0 R T G A G E I NS -PECT 10N PLAN of LAND I N B A R N S T A B L E SCALE: 1"= 50' APRIL 18,1986 A afpN LO Z E i 43 9 coo± S F. LoT ?3 N . N 34'+ •(0 Q�y i F I CERTIFY TO JOHN F MEADE• ESG. .NORTHEASTERN MORTGAGE CO. ANT.) ITS TIT'_F INSURANCE COMPANY THAT I HERE. TS OR EASEMEMTS PF AN WAS PREPARED UNDER MY IMMEDIATE N SUPERVISION , EXCEPT AS SHOWN AND THAT TH .... .T.nn nc TUC nwC1 I 1 Mr, AS SHOW ' \ � � f.ter' ry..,,• . \SWAB Iih� � ,�.r• � � 1c. FA �� �� - mob, Y •'d `II .). . , � So •.. .,,�- fir,, I r . t i 7• r0rr.eaFa�� CERTI FI ED PLOT PLAN B w MA 2'5-rb N S /h l L. —S I N •:. : /1Cv 1:C,;i 1 1/ 9�y SCALEI ` � Yo DATE I DREDGE ENGINEERING ENGINEERING CO 11V CLIENT_.e..�,. I CERTIFY THAT THE PROPOSED EGtsTEflE REGISTERED JO® N0. }� � evILDING• SHOWN ON THIS PLAN CIVIL. DR.BY, LAN® CONFORMS TO THE ZONING LAWS EM®INEE_� �.•St�f�V� —�—��-"'— OF BARNSTA9LE I MASS.., 712 MAIN STREET CH. BYE NYANNIS, MASS. / 4A —E EO.LANO IJRVEYR SHEET ®F S 0 �p(K- • I 611 I I I milii�' 1l l ��1 — a F...-_ � .__..._........... ! —/0= 2 e� • \`IL 1__,. 1. 1 ► .I a� � o� ��_I�(I J I� � ja di I��1 �L►��,; �I�► �i��1-ail J h b 1. �t own of Barnstable y� The T : . ,s1 4 0g Department of Health Safety and E IIvironmental Services 059. Building Division 367 Main Street.Hyannis MA 02601 Ralph Crossen Office: 508-8624038 Building Commissioner 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 building containing at least one but not more than four dwelling units or t structures which la cg art adjacent nt to such residence or building be done by registered contractors.with certain requirements. a� `; =; Estimated cost 9sa0 , Type of Work: RP ZI c X_- Address of Work: %5 .e/S Owner's Name: d - Date of Application: ���- I hereby certify that: Registration is not required for the-following reason(s): ❑Work excluded by law []Job Under$1,000 ❑Building not owner-occupied XOwner pulling own permit Notice is hereby given that: UNREGISTERED OWNERS PULLING SOWN PERMIT OR DEALING VENT WORK DO NOT HAVE CONTRACTORSR I 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: 7 O� Registration No. Date Contractor Name OR 3 Daced Owner's Name q:forms:Affidav `� �11 �• (pT2 Assessor's map and lot--number .......................(..........�G,......c�... yofTNe.ro� Sewage Permit number 0 ��.! . .. ........ . �............... BABB House number . ail — . [� AOL LE, p YFY TOWN OF BARNSTABLE s ' BUILDING INSPECTOR APPLICATION FOR PERMIT TO l( n� t<< U -(} n,i --- TYPE OF CONSTRUCTION .... .©a k' c.f�+wt�. ................................................................................................................. �'.�r:....... ............19 . TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: o t ...........s d r\�� e K 1�2, J,Y\ C.3 4.: cS>; k� .. - Location ....... ...... °�. . ....... ................... ...... ...........,. .:. :.` s................. ..... Proposed Use ......9.` 7 i e; .t ....................................................................................................................... ....... ->_ ;a Fire District �`! i f�5 ZoningDistrict .......... ............... ..................... .................................................. ..!... ..:........ ....... Name of Owner rq•.� rt< Address C.c.,,,,� z.... .�. .. .................................................................................... Name of Builder .....d1. ✓.`?.!.I�.� �..................................Address .................. .................................................. - p Name of Architect t � tee{`: .P............. Address Number of Rooms Foundation Q����S C���°� Sti }} ....................ii............................................. } .......:....... �) /� 1 �:�rice,►. ..................Roofing S r��t� Exterior ...............�... .--. ...........y.......V...................... ........................V. . .......................................... Floors .A.ReEl"....... � i.��e..l. .Interior. ..............�..!!�?e..........�Y.P,Ss„�ka�............... . .:.:. ............................. .......... ........................... r r Heating �"1.... ...... A. S>... . ...... ................. .Plumbing ..................2........... ..........1- ........ �sna�S� "�j, Fireplace .........� .� ........... .. C. ...................Approxtmate Cost ................y.d.f:..8 ' `'.............................Definitive Plan Approved by Planning Board ------------------------- ______. Area ........ 7� .................... •� Diagram of Lot and Building with Dimensions Fee ~:-"........... SUBJECT TO APPROVAL OF BOARD OF HEALTH\ d04) \* r f f �s s, ,.f OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Nam .................... .......... Construction Supervisor's License ....�. •,'� �n.:yS......... BAYSIDE BUILDING CO./ A=61-42 25956 One Story No ................. Permit for .................................... Single Family Dwelling ............................................................................... Location ...Lot...72, 5.4.9...Whi.s.tl.eb.e.rry Drive ....... .. .... .... .. .. Marstons Mills ............................................................................... Owner .. Bayside Building Co. ................................................................ Type of Construction ...F....r........ame........................... ................................................................................ Plot ........................... Lot ............................... Permit Granted .................................-January 10,.........19 84 Date of Inspection ....................................19 Date Completed ....................................19 } �7s '�..� JA D 40 ,y r N N i y N �1 e vT7 , G .+ V'N ( ( l 0 T .7 Z 1 43,900 57r- e P 1` •roNS A i CERTIFIED PLOT PLAN 7 zIN L✓�l i s .£8 it t�( of a 1 i I SCALE, / =11D DATE , Il elcf, f REDGE E N ERI (3 C /�NC� Y <. �• r.0 a/r0A t 101V y . I CERTIFY THAT THE . CLIENT r RC-19 rI => r kGISTERED IitOiSTERtcD SHOWN ON THIS PLAN IS LOCATED Joe MD. �3 3v vA : '_ a RED - ON THE GROUND AS INDICATED AND LECONCIVIL LAND -*�r� 'Q E��i<tc y > FORMS pq,SY NOINEER SURVEYOR � A r' TO THE ZONING LAWS ' • I ,�sT,-�!,, OF 3tl ea-A,34-jr , MASS. n B. �" . 712 MA N STREET �" �--r••— /, �f ` H YA N R I S, MASS,, SHEET.�,OF ` A E REG. LAND SURVEYOR