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Home My WebLink About0058 SETH GOODSPEED'S WAY 5g Seel-� Gao�sPeec c.�� . , 1 TOWN OF,BARNSTABLE BUILDING PERMIT APPLICATION Map i. Parcel Application `— Health Division Date Issued Conservation Division Application Fee 1�5 Planning Dept. Permit Fee - Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address Village S-v-��1 Owner LAM.2_zS-C Address Telephone_ S�G% L_ � "IE Z7 7 ' r Permit Request k 1A L_f k_t A \fW,-)0 it�-&L c T s . Square feet: 1 stLr: existing AQ�Kproposed Q 2nd floor: existing 0proposed Total new \CAA0 Zoning District Flood Plain Groundwater Overlay Project Valuatio ��r Ow Construction Type - . Lot Size 3 f�+GQC'S Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family 'Q Two Family ❑ Multi-Family(# units) Age of Existing Structure ka�'1 Historic House: ❑Yes ®'No On Old King's Highway: ❑Yes W40 'Fu Basement Type: ll ❑ Crawl ❑ Walkout ❑ Other Basement Finished Area (sq.ft.) ® Basement Unfinished Area (sq.ff.4 U Number of Baths: Full: existing new Half: existing oil new-, Number of Bedrooms: existingQ new , N*1 ±� Total Room Count (not including baths): existing I- new � First Floor Room Count Heat Type and Fuel: 5/Gas ❑ Oil ❑ Electric ❑ Other ,q 5-4 Central Air: ❑Yes Vo Fireplaces: Existing New O Existing wood/coal stoves❑1Q'33 G& Detached garage: ❑/existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: LEI existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Wc)LA&P�.L_ Telephone Number Address �TS �45,OiS� � ' C) License # C)0, Home Improvement Contractor# 1 C)S Zq 1 Email _ n , �-- Cry ';. \Worker's Compensation # ALL CONSTRUCTION DEBRIS ESULTING FROM THIS PROJECT WILL BE TAKEN TO X*NL 1 kA P SIGNATURE DATE o S FOR OFFICIAL USE ONLY y APPLICATION# -DATE ISSUED i MAP/PARCEL NO. ADDRESS VILLAGE V4' OWNER DATE OF INSPECTION: FOUNDATION FRAME t INSULATION 4 FIREPLACE ELECTRICAL: ROUGH ' FINAL PLUMBING: ROUGH I FINAL GAS: ROUGH FINAL t FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. ' - CAFE COD INSULATION [�;-/] HEIR OSAIJ 11AM5155 SPRAY FOAM 1USPINOIp RAIIJ Oul"R1 INiul 110" RIISIN01 1-800-696-6611 Town of Barnstable Regulatory Services Building Division b Lt% 200 Main St Hyannis, MA 02601 Date: ��3 r� Dear Building nspector Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed & completed the insulation and weatherization work at the property listed below. Cape Cod Insulation did this in accordance to the specifications listed on the building permit application. All work has been inspected by a certified Building Performance .Institute '(BPI) inspector. All work preformed meets or exceeds Federal & State Requirements. Property Owner Property Address Village Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrestricted Ceilings ( ) ( u) (-2 Slopes ( ) ( ( ) ( ) ( ) Floors Walls ( ) ( ) ( ) ( ) 6VOr k r Jror,►e,01 (' D Sincerely 2TeHrE ssi r, President Ins ation, Inc. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION c4oap Parcel Applicati n #Health Division B Date Issued Conservation Division Application Fe Planning Dept. A ✓,4* �FAj' Permit Fee Date Definitive Plan Approved by Planning Board B Historic - OKH _ Preservation / Hyannis Project SJTet Addr9.,ss let, Od �Gt Village Owner xy Address --&4 Telephone d " Permit Request Udir ) ix-14 . eo ll WO/Al C �,, �< C^�✓✓l tit. ; Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District ,mil Flood Plain b Groundwater Overlay Project Valuation �� U U Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family -5C Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric . ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: 0 existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes *No. If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Telephone Number PJ -_7 Z 14 Address License # U Home Improvement Contractor# f'� Email I Worker's Compensation # D666Q-'31 C G ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL_ USE ONLY -APPLICATION # DATE ISSUED : MAP/PARCEL NO. h ADDRESS VILLAGE _ r I i OWNER i i Ir DATE OF INSPECTION: ' 'FOUNDATION , t FRAME INSULATION FIREPLACE } ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. Uwe Permit Authorization �i0�� mass save• � Form coxnuwm Site ID: S00002033001 Customer: AMY ROSE SAGER I, AMY ROSE SAGER ,owner of the property located at: (Owner's Name,printed) 58 Seth Goodspeed Way OSTERVILLE (Property Street Address) (City) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform'nsulation and/or weatherization work on my property. Owner's Signature: Date: •.00000••••••00000••0••000•00000000000000000000000000060000900000oose FOR CSG OFFICE USE ONLY Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: Casa (fCA amok , k 121 J Zo110 Participating Contractor Date ©f'D Conservation services Group • 50 Washington Street,Suite 3000 • Westborough,MA 01581 • 1800.480.7472 ❑. j �° For Office Use Only Rev.102015 -----.--.----------•— ----•------- ---- -- ---__ —._._..__� Massachusetts Department of Public Safety : Board o _/ f Building Regulations and Standards License: CS-100988 Construction Supervisor s' HENRY E CASSIDY " 8 SHED ROWr. WEST YARMOUfH Expiration: Commissioner 11/11/2017 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Coritxactor Registration Registration: 153567 Type: Private Corporation CAPE COD INSULATION, INC Expiration: 12/15/2016 Tr# 259188 : . HENRY CASSIDY _ 18 REARDON CIRCLE SO. YARMOUTH, MA 02664 Update Address and return card. Mark reason for change. i •:; 20M-05/II Address Ej Renewal Ej Employment Lost Card ..._. ......_......................... . �e amzonoazcuea.CC�o�C�/�CculOac�ccdeCld -Q •Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date, If found return to: eglstration: 1.53567 Type: Office of Consumer Affairs and Business Regulation j xplration: Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 PE COD INSULATI'ON:;:..INC:`.' NRY CASSIDY REARDON CIRCLE"'. YARMOUTH,MA 02664 Undersecretary N valid wi ut sign�— e r 1'ie Uoinmonwealth of Massachusetts Department of Industrial Accidents Office of Investigations =- 600 Washington Street it` : Boston, MA 02111 www,mass.gov/dia Worker's' Compensation Insurance Affidavit; Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/lndividual)::l am ' � 1 J�✓ '^ Address; M lv/A 0 T�� ' r City/State/Zip; TtA-, /i,My,i Phone #: d W �t,� ' d '�i1 v Are you an employer? Check th• appropriate box; — 1, ,1 am a employer with �• tom_ 4. ❑ 1 am a general contractor and I Type of project (required): employees(full and/or part-time).* have hired the sub-contra 6, ew construction p ) sub-contractors ❑„N tion 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7, C] Remodeling ship and have no employees These sub-contractors have working for me in any capacity, employees and have workers' ' 8' ❑ Demolition [No workers' comp, insurance comp, insurance.# 9, ❑ Building addition required,] 5, ❑ We are a corporation and its 10,0 Electrical repairs or additions 3 ma a homeowner doing all work officers have exercised their 1 1,❑ Plumbing repairs or additions y [No workers' comp, right of exemption per MGL insurance required,) t C. 152, §1(4), and we have no 12,❑ Roof repairs employees, (No workers' 13.� Other ' comp, insurance required,) •Any applicant that checks box b 1 must also rill out the section below showing their workers' compensation policy information. r Homeowners who submit this af6avit indicating they are doing all work and then h've outside contractors must submit a new affidavit indicating such. 'Contractors that check this box must attaphed an additional sheet showing the name of the sub•cond-actors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their workers' comp, policy number, 1 ant an employer that is providing workers' compensation insurance for my employees, Below is the policy and job site 4, fgrmallon, ��J+ Insurance Company Name; '\' & ��', �V O Policy # or Self ins, Lic. #; 1100 °`� ✓� Expiration Date;_ I / Q� J6b Site Address;_fad) �__. _...;.. City/State/Zip: �'�'Vll�� t 'V� Attach a copy of the w0rlcers' compensation policy declaration page (showing file 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 as well as civil penalties in the font 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• insura covera e verification, I do hereby cerl/y d the pal ` an penalties of perjury that the information provided Bove s true and correct, Si nature; Date: Phone#: Official use only, Do not write in this area, to be complete by city or town official, City or Town; Permit/License# Issuing Authority (circle one); 1, Board of Health 2, Building Department 3, City/Town Clerk 4, Electrical Inspector 5. Plumbing Inspector• 6. Other Contact Person: :J CAPECOD-27 BDELAWRENCE CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 6/30/2015 %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 pblicy(les)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 Irf lieu of such endorsement(s). PRODUCER CONTACT NAME: Rogers&Gray Insurance Agency,Inc. PHONE Fax 434 Rte 134 /C ac No: ($77)816-2156 South Dennis,MA 02660 ADDRESS: INSURERS AFFORDING COVERAGE NAIC rt INSURER A:Peerless Insurance Company-see LIBERTY MUTUAL INSURED INSURER B:ATLANTIC CHARTER INSURANCE GROUP Cape Cod Insulation,Inc. INSURERC: 18 Reardon Circle INSURER D: South Yarmouth,MA 02664 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER;. THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. A[ POLICY EFF I SR TYPE OF INSURANCE POLICY NUMBER MMIDDfYYYY MM DD�XP LIMITS LTR A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE MOCCUR CBP8263063 04101/2015 04/01/2016 DAMAGE TO RENTE(37— PREMISES Ea occurrence $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 pqPOLICY a jECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY o COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DEC) I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y STATUTE ER B ANY PROPRIETOR/PARTNER/EXECUTIVE F N/A WCE00431901 06130/2015 06/3012016 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 II,yes;describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) Workers Compensation Includes Officers or Proprietors. Additional Insured status is provided under the General Liability and Auto Liability when required by written contract or agreement with the Certificate Holder. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cape Cod Insulation,Inc THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 18 Reardon Circle South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ©1988.2014 ACORD CORPORATION, All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD L rZJ TG C �� , 5�� pLA A Town of Barnstable Regulatory Services Richard V. Scali,Director J "` hUSK Building Division BARNSTABLE 1639. 16 ��g a iOlFp (A Thomas Perry, CBO Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.nia.us Office: 508-862-4038 Fax: 508-790-6230 February 19,2015 Mr. Michael Baker 78 Bridle Path Marstons Mills, MA 02648 Re: 58 Seth Goodspeed's Way,Osterville,MA Dear Mr. Baker, On February 12,2015 application'was made to finish the basement at the above referenced address. Please be advised that the project cannot be permitted as submitted because of the following reasons: -only the Zoning Board of Appeals can authorize the kitchen; -smoke/heat detectors must comply with 780 CMR 81h Edition(with MA amendments) sections R314 and 315 -ceiling height must comply with R305; -rate of air exchange must comply with R303 and IMC Table 403.3; -insulation must comply with 2012 IECC Table R402.1.1. As soon as these issues are clarified,the application process can continue. If you have any questions,or feel aggrieved by this decision,please do not hesitate to contact this office. Sincerely, Paul Roma Local Inspector ' J iTf t Q ez2e - . Adore 4 l�o-i ❑EM s via 0 I�a n� zud:L Type ItTcs� ' / ayees{fnll.and��_-* ha�s:l�c�dt�sub�acEvcs. . 7 g a sole progaf#ar orpar*r- listed an fire tied shy ❑ ship and Irnre no,employees 2he=sab oo�Ftadns have 8. ❑Demafdim- formiu any capadLg l�ewwi=, I ❑ E3ns ngaddifiOtl [IO•wadmss =MP-�L comp_ $Se acal of additions I 5_ ❑ ce a We a eocparatramandiis IO-0 �'rs �_El I am a hnmsovener dumb all wad, my Win-;sed lbeir 1�Pi�mg repairs or a�rdons rr�Tf END wolinr 'COMP- �afemimpfidmPerLIUL 120 Pnafnpaim c 15Z§1(4} aad.wehaste cnrnrnn_r--e 1•F 13.E Qfiur emfClopees-LI`la�� . camp_=m ancz reqakuLx 37 - rira��zt cheRsbar Ql umsts]so faoati�s�cff—b9avrA--ag 3�eawo�Ces'mam aupaTsj #110r.. tnes Vrhu s►�d�::. Y crY =II -�T the�*re tatlz�coati�rtusmast svba�ff a �dsrSt maw sash II'fnj rh lthis boC m'o-St Cheri aIlzOd]izaasl Shot shtr�gthelaaaa6Ffbe zm35tFdauhete�pp]aL�SE Srsb.-'P_ _ the WB-Cm a— h..M=MDUP--,dZ1` lie saw walm&rimy p0hy-mbi- �ruu r�arnjflvptr i}ccttisgra•tjg fttvrkexs'eon in-,r=C9 far lay eZQA0yess. Below is 8tepazky and job-,&z • u�ore�•,a4fr�tr. -. - Ip CompanyN=le- E�hcy ure€f-isss_Iicial�ate_ f±Eacli ae copy of fhe WUrk Le caurp ton pory dCCLt=ti M page•(shV"Wing the P6HCy n COMB=arzd�aLion Xl�e): Fails to scent:cavcrap as - Secfina25A ofTom.c 152 can Imil to�impo-ihan nf-caMi-I pe�ies of a fine ug'to LSOU(ID and(Or on$ imPigo s3 well as cirl genalfia m$e fuffi of a SIr7F l0} ORDFaad a fine u€nptoSO_QC?a d ap agaivs# violaiAr Be advised fast a crtgg offfiis sit maybe faded to Bse Ofnrp.of. scesEigatinas Of to DZ coverage vMzffca#ioa_ I cfa sreby P rzrcdrr - - �stcdpe aN=vfp�p f iat$te informdiau pra sided agave is hzra tmrT carry �IF1LAfT*r*�- iv. Isom E zciaL z>ss ari�� D.,auof t4rdsiu 6*area,fa bs campieh�d by City ar k wzl of ciaL Cif or Town > ff are[Zse L Boarde-f$e-Tffi 2.Bm rxag =M±j atyTu uCork 4.IIe iealFnspechOr .P hr_gxcFnr Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supen•isor License: CS-093325 MICI AEL B BAK R ' 78 BRIDLE PATH Mantons Mills MA 02648 i �J Expiration Commissioner 08/06/2015 i i Office of Consumer Affairs and Business Regulation - 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration - Registration: 165291 Type: Private Corporation Expiration: 1/27/2016 Tr# 247914 TRADEMARK PROFESSIONALS MICHAEL BAKER 78 BRIDLE PATH MARSTONS MILLS, MA 02648 Update Address and return card.Mark reason for change. Address Renewal Employment Lost Card SCA 1 G 20M-05/11 n�//,; 7p;,.,,,.rreo•ittoeu///:,�'C�llc, �,r,/rcJe/% License or registration val' for individul use only Office of Consumer Affairs&Busifiess Regulation before the expiration da$f. If found return to: II,OME IMPROVEMENT CONTRACTORX. Office of Consumer A irs and Business Regulation egistration: 165291 Type: xpiration: 1/27/20-16 Private Corporation 10 Park Plaza-Suit 70 Boston,MA 02116 TRADEMARK PROFESSIONALS MICHAEL BAKER 78 BRIDLE PATH g � MARSTONS MILLS, MA 02648 Undersecretary No valid without signature ��E r Town of Barnstable Regulatory Services 1M�ASS. `0D' Richard V.Scali,Director jOr 0.1p.. 0. 0 Building Division _ ......-............_........................ ..._. - - — - .._.._...TomPerrp;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 ABuilder L Lkg-2.C�- as Owner of the subject property hereby authorize LA kC C—1 SIAINLC'9 to act on my behalf, in all matters relative to work authorized bythis building permit application for. (Ad&ess of Job) Pool fences and alarms are the responsibility of applicant. Pools are not to be filled or d before fence is ' ed and all final inspecti e perfo ed and accepted. ature Owner Sig na e of Applicant Print Nam 'Print Name /)I , Date Q:FORMS:O WNERPERMISSIONTPOOLS Town of Barnstable Regulatory Services THE rO�,k Richard V.ScaIi,Director Building bhrision BATxsrABM ' Tom Perry,Building Commissioner Mass 16.59. a.0� 200 Main Street, Hyannis,MA 02601 www town_barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-623 0 HOMEOWNER LICENSE EXEMPTION Please Print - DATE: JOB LOCATION- number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state rip code The current exemption for"homeowners"was extended to include owner-occupied dwelIings 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_ DEFII WON 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"homeownee'certifies that he/she understands the Town ofBarnstable 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 2.1S) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor, The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRFSS.doc Revised 061313 i tip'•�� - _ 71 o I - Iona n C, TA�►It � j�o .• R 11 1000 CAL L C-A�.44 �� T � ftit,liA{iDA. BAXTEit �,+ No.,244s8 ��GTE�� • LOGATIUN OS1">°�Ulc�c.L /Vl� l cG;ZTIt=Y a`iA 7 Tt4►_ 'FaL)wDaTlow SUcw►.3 Pt �t.l R(.(=`K�►.;� uE►?E.Gi,i �c:iiri�'L�CS W (TiA Ti-tE St DE Lt►-�E A.1.i� 5C-T13��t.K Q�QL%tiZCNici�ljS CiF= TNc G i c w►.) c�= B A.2.h1S AFC LC LA h Cov 2T fir: I.! 3 2 PArc ' .RC-GiSiLiZ�o iJ�.1..ip Sti2�•'�`iocZS p jt-1lS VC-Aw IS Li 13/aSc� Utz( Ac.l _ US'T>r2V1LLC c, lvll�SS. \WS'['��:rLtc=.N•i `iU��/i=� � "T�aL Cyr=�SciS Si�1�:i.JI�D APi�L.1G/�.l�lT _ t-t,T E3E U,Ca ) 'iv DeTi=;zM(wit_ Lo'T' Ll1,1�5 - s_ - 44P1r Ca . I C SYSTErr1 INSTALLED IN MUST aE ALLED U is ma and lot: number COMPLIANCE ssesso WITH ARTICLE II `F , .G dl le - - 3 74 1 SANITARY STATE CODE AND REGULATION TOWN . Sewage Permit number ..........................................................' S. _ EtO�o ^, TOWN OF ',BARNSTABLE e i DAWSTADLE, i 039""` BUILDING INSPECTOR 9pp,p� . C. 'E0 ypY�' y APPLICATION,FOR PERMIT-:.TO �........ ... ....................................... TYPE OF CONSTRUCTION n..... ............................................................ TO THE INSPECTOR OF BUILDINGS: The undersig ed hereby applies for a permit accordi g to the following inf rmation: Location ........ ...`S`�.... ..... . .................J........ ✓. ................/....................................................: Proposed Use ..... .... .... .. ....... .Zoning District .. /.1..:.. .....................m........................Fire District .. ...... .... ..... ..... .. .............. . �A� r Name of Owner ....... ..... .......................... v....................Address ....... ... ........... Nameof Builder ....................................................................Address ..................................................................................... Name of Architect .................. .,................................................Address ................................................... .. ..... ........................... 1.............................................Foundation ..... � ��Number of Rooms ................... .. ....... ......................................................... Exterior f l ...Roofing ......... Floors Interior ......... �. ............. ...... ..... .. Heating ........ ./.. .... �� ............................Plumbing ............................................................. FireplaceApproximate Cost.................................................................................. ...... c.............................. Definitive Plan Approved by Planning Board ---------------_---------------19________ . Area ....................... Diagram of Lot and Building with Dimensions Fee .... � . ......................... SUBJECT TO APPROVAL OF BOARD-OF HEALTH I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ................. ..,.. �r� Capewide Development 189161 one story No ............. Permit for .................................... sifgle family dwelling ..................................7...................................... Rebecca Lane Location ................................................................ bsterville . ............................................................................... Owner Capewide Development ...... ............................................................ - Type of Construction .....................frame.................. ................................................................................ Plot ............................ Lot ..........#50...................... December 31 76 Permit Granted ........................................19 Date of Inspection ..... ..........19 ..... . .... ... 19 Date Completed PERMIT REFUSED ................................................................. 19 ........................ ...................................................... ............................................................................... ............................................................................... ............................................................................... Approved .................................................. 19 ............................................................................... ................................................................................ Assessor's map and lot number ...' %/ �ewage Permit number .......................................................... THE.� TOWN OF BARNSTABLE ii i EAWSTAXLE, i "6 9. BUILDING INSPECTOR �'0 YPY Or• APPLICATION FOR PERMIT TO .... .................... . .:.... ......... ......... ......... .. ..... . ...................................... TYPEOF CONSTRUCTION `......... . ......... ......: ......... ......... .................... ......... ......................................... ........ .. .........19........ r TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies fora permit according to the following information: Location ................................................ / ice o Proposed Use ...... . Zoning District Fire District .... .. ....... ... ......... ..................... ......... . ..... r Name of Owner .. ......... ...................Address Nameof Builder ....................................................................Address .................................................................................... Nameof Architect ..................................................................Address .................................................................................... Numberof Rooms ...................'..............................................Foundation ........................................:..................................... Exterior ........................ ................................................Roofing ......... .. ......... ...... .. ...... ......... ........ ..,................................... Floors ..................,...................................................................Interior ...................:.......................: ....................................... e Heating .......................................... .. .................................Plumbing .................................................................................. Fireplace .'................................................................Approximate Cost Definitive Plan Approved by Planning Board -----------_______-----------19________, Area . .... .... ............................. Diagram of Lot and Building with Dimensions Fee ....::.: ..........:......................... SUBJECT TO APPROVAL OF BOARD OF HEALTH A i I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name ................... .................. c ........... Capewide Development A=1464r"(not plotted) 18?0,1 one story No ................. Permit for .................. ............... . single fa ly. dwelling .......................vim. ...........;. .... ....... .. Location%. ......................... ............... ......................... .... ................ Owner Capewide Develd ent.................................................... frame . Type of Construction .......................... ............... ......................................................11. ......... .. .......... #50 Plot ............................ Lot ... ............. ............. Permit Granted' ......P�cemaL.V..3.1. 19 76 Date of Inspection .....................................1 9 Date Completed .......................... ............19 PERMIT REFUSED ................................................................ 19 ......... ... ... .. ............. .... ..... ... .. ..... . ......... .../...... . ............... .. ............... ....... ...... T ..............0............ ............ �� ... ....... ................ ............ ........ 91,9 Approved ..................... .......—L9 ................................ .............................................. .................................... ......................................... -3 Z-//Zo CAPE COD TOWN OF BARMISTABLE INSULATION 2g12 r R 12 PH 2: 30 FIMO sS SIAMISSS SPRAYFOAM SOSVSNOSO OATIS OOTSSSS m'uI tO ""'NOS r 1-800-696-6611 DIVISION Town of ��✓�j � Regulatory Services Building Division Address- Address 2 - Date: 31&0 I '), Dear Building Inspector Please accept this Affidavit as documentation that Cape Cod Insulation,Inc.performed& completed the insulation and weatherization work at the property listed below. Cape Cod Insulation did this in adcordance to the specifications listed on the building permit application. All work has been inspected by a certified Building Performance Institute (BPI) inspector. All work preformed meets or exceeds Federal&State Requirements. Property Owner Property Address Village I Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrestricted i Ceilings ( ) QK (30 Slopes Floors Walls ( ) ( ) ( ) ( ) ( ) C j He *, Inc. t Ca TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel No-3 Application # �EJ I (� Health Division Date Issued Z. Conservation Division Application Fee �1 Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board ^J 311 /1.2OF— Historic - OKH Preservation / Hyannis Project Street Address Village Ul Owner Address Telephone ell Permit Request //mew W ycew, air C I �'� -� D .� � • �G DDO 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 Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new_, a Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count ' Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove.:-0 Ye ❑ No co Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing O-new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appealzo orization ❑ Appeal # Recorded ❑ Commercial ❑Yes If yes, site plan review# } Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) �ed � ho-h— Name . G Telephone Number g_ 775 — l Address License# 00 Home Improvement Contractor# �3�67 Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTIV FROM THIS PR JECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION# t DATE ISSUED MAP%PARCEL NO. ADDRESS VILLAGE OWNER T DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL s FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. 3 'I i 10 Park Plaza = Suite 5170 it Boston, Massachusetts 02116 Home Improvement Cojitractor Registration Registration: 153567 Type: Private Corporation Expiration: '12/15/2012 Tr# 206433 CAPE COD INSULATION, INC :. HENRY CASSIDY - - 455 YARMOUTH RD. HYANNIS, MA 02601 Update Address and return card. Marl:reason for change. U Address I—I Renewal I ._I Lnrpinymcn[ I I Lust Card Ai ii ours-U•LU-�i;lU l'_'lii U16'.L y - 'oi+wucr Affairs q�'�ttusyne:/e lieguI rtiun License or registration valid fur i:aividr:! use:�::!,, HOME I�PR 0Z Wrt(Nf�ALA7f��`�"c`�� before the expiration date. if found return to: Registration: 153567 Type: Office of Consumer Affairs and Business Regulation �1. 10 Nark I lava-Suite 5170 't Expiration: 1 211 512 0 1 2 Private Corporation Boston,MA 02116 >sf' COD INSULAI-ION, INC :�!t:Y CASSIDY 5 YARMOUTH RD. .� (ANNIS,MA 02601 _ Undersecretary Atalid ith [sio ttlre *- Nlassachusctts Dcl)iu'tlrtcot til'Pulllic Sabel% Board of Buddill" Rc;;olations and ltanthr('Is Construction Supervisor License License: CS 100988 . I!s HENRY CASSIDY 8 SHED ROW WEST YARMOUTH, MA 02673 -� Expiration: 11/11/2013 l'uuuuixsi"'r'' Tr#: 7620 I— The C ri otruo2-nvealch of Masscz Ch Ilse US x D ep a r r m e?i i of In d tz s r r ia 1 A C C id e i i.t S 0 81 Ce OY 600 Washington Strev Boston, MA 02111 la wyv)v.,t,ass.gov/d' "i-Vo vlcca-s Cocripensation lrisui-aiice Affidavit: Bull d ers/Contra cto rs/E A )Lic. inl Iiifol-iii.a-t.-iori P I e kk S a r 11 t -Y,4 rlml-( I I:,/S l.j t tJ Z 11): Phone ro AI r you Lit] C1rkPl0)'rL-? Check th iappropriite. box; Type of project (requictd) I M.11 Cl (;Ir1)-)10YCI- with am general contractor and I 6. ticti New consiron Clrlptoyc.er (full and/of part-time)., have hired the sub-contractors listed on the attached sheet. Relliodinling I art I stir, piol)rietor.or partner listed Culd have 110 tillifloyces These sub-contractors have Dri-nolition employees acid have workers' v"0111.1-Ig for uric Ill dzy Capacity. comp. insurance.; 9. Bulldl.ng addition P-,Io Yeorkcrs' comp. insurance comp. F] We,are a corporation and Its I 0,E] Elcarical repairs or additions rcquirrd] officers have exercised their Ln Pluiribing repairs or additionsl Lim a boincowncr doing all work right of exemption per JN4GL rnyscff. J'No workcrs' comp. C. 152, §1(4), and we have no 12.E] Roof repairs ilMlY�111C.0 reClUircd.j employees. [No workers' )3.E] OLljer_&4tgL4�-Lj-Q-tA01,- comp. 111sulauce requiftd.)-------, Any a pl)I icj t,I that checks box 11) must also Fi 11 out the section below showing Jf worW's'compt;n5i'601)policy information. Hunicowncrs who sulornit this affidavit indicating they act;doing all work and Lhoil hire outside contractors must submil a new aft-Iddyll indIC46fig SUCII. 4'01111CIC101`5 that chuck this box must attached wi additional sheet showing the name of the sub-co6tractors and state whcilirr or not ihosc onlitics hd,\,C. Up1vY,;CS. If U110 sub-contractors huvc employees,they must provide their worlccrs'comp.policy number. ,,m at I ctrip hqe r that is p ro vidirig workers' Co tnpenso rion insurance for my employees. B elo I-v is the polio:)!and job site. hi:,manco Cowl)zi.ri), Narnt;:___At I t-I lis. LJ c. Y: (&44 001�z-�-9 Expiration Date:__ z;L-- C I�y/S L a t t/Zlp: mb `)Ito Addrtss:- Amch it (,.oil), of the )Yol-kers' compensati / �W V�` !��! �C-FJ5 5� lan policy declafation page (showing the policy nurriber and expiration date). FaIlLUC to secure coverage as required uoder Scction 25A of MGL c. 152 can lead to the imposition of crit-ninal penalties of J IMIC III) to $1,500.00 and/or one-yeaj- unprisoament, as well as civil penalties in the fon'n of a STOP WORK ORDER and a fine. Idl.Lip LU $250.00 a day against the violator. Be advised that a copy of this staterneot may be forwarded to the Office.of tovcstigatloas of dir, DIA for insurance coverage verification. do hereby certify fet- e Pa. CULd penalties cfperjury that the iriformarionprovided abolle I.s Ifr arid correci. 'Pen", 'e- Oena Date: �21 O/jrcial use 011/Y- Oct not write in this area, to be completed by city or town off cinl 'f, e I(')' L)r U)Ytl: Permit/Licens issuing �,U(h 0 ri t7y (circle one): S. Plurribing In5pectOr 1. board of Health 2. BUildinig Department 3. Cirl,iTuiYn Clerk 4. Ci(:ct1-ic1xl Inspector o. Other Plione L Client#:4597 CCINSUL ACORD CERTIFICATE OF LIABILITY INSURANCE D2/02/ 1DD1� THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON 012 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. e certificate holder Is an ADDITIONAL 1NbUKtU,the po Icy les must be endorsed. ,su jec o 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 endomement(s). PRODUCER NAME: Margaret YOung Rogers&Gray Ins.-So. Dennis !PHONE FAX 434 Route 134 A/c No ExtI:508-760-4602 (Alc, No):877-816-2156 afAAIL P.O.Box 1601 ADDRESS:Voungma@rogersgra m y,co PRODUCEK South Dennis,MA 02660-1601 I CUSTOMER ID#: INSURERS)AFFORDING COVERAGE E NAIC# INSURED INSURER A:Peerless Insurance 18333 Cape Cod Insulation Inc INSURER B:Ohio Casualty Insurance Company 455 Yarmouth Road --- Hyannis,MA 02601 INSURER C:Atlantic Charter Insurance INSURER 0:Commerce.Insurance Company 34754 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR ADDL SUBR POLICY EFF POLICY EXP A GENERAL LIABILITY CBP8263063 04/01/2011 04/01/2012_EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES(Ea occurrence) ,$100,000- CLAIMS MADE X OCCUR MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $21000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 PRO D AUTOMOBILE LIABILITY 11 MMBCKVMK 04/01/2011 04/01/2012 COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) 1,000,000 ALL OWNED AUTOS BODILY INJURY (Per person) $ . X SCHEDULED AUTOS BODILY INJURY Per accident) $ - _ PROPERTY DAMAGE X HIRED AUTOS (Per accident) $ X NON-OWNED AUTOS $ B UMBRELLA LIAR X 'OCCUR ( 0001254514645 .04/01/2011 04/01/2012EACHOCCURRENCE 1$1,000,000 EXCESS LIAB -CLAIMS-MADE AGGREGATE $1,000,000 DEDUCTIBLE - $. X RETENTION $ 10000 C WORKERS COMPENSATION WCAOO525902 O6I3OI2O11 WC STATU- OTH-' AND EMPLOYERS LIABILITY YIN 06/30/2012 X. ..TORY LIMBS . ER ANY EREXC EXCLUDED?ECUTIVE OFFICERIMEM r "J NIA E.L.EACH ACCIDENT $500,000 (Mandatory in NH) E. DISEASE-EA EMPLOYEE 500,00. If s,describe under I_ L DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) Workers Comp Information Included Officers or Proprietors CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. I AUTHORIZED REPRESENTATIVE i 01988-2009 ACORD CORPORATION.All rights reserved. ACORD 25(2009/09) 1 of 1 The ACORD name and logo are registered marks of ACORD #S77368/M68179 MEY sip w\TE- mA tL .� mass v coffffamm s' y :srnw:na+¢ene.pv.muarr <J ■ ERMIT AUTHORIZATION FORM —, owner of the property located at: (Owner's Name, printed) S� SST Coo SiyE� VAy (3si ✓i LLE A44 (Property Street Address) (City/Town) hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed below to act on my behalf and obtain a building permit to perform insulation and/or weatherization work on my property. 0A --- Owner's Sig re hl� Date: FOR CSG OFFICE USE ONLY Conservation Services Group has assigned the following Mass Save Home Energy Services Participating Contractor to the above referenced project: CAPE 60 J -1-nSUC.4 i oP a + k �L Participating Contractor 6ate Rev.12132011 Town of Barnstable *Permit# 60(a Expires 6 months from 'sue date Regulatory Services Fee Thomas F.Geiler,Director p�G 1 gLE Building Division 6PRNS�P Tom Perry,CBO, Building Commissioner O\N 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY nn Not Valid without Red X-Press Imprint Map/parcel Number 14U — yl�� Property Address Cam" ' -, k ,�L B V✓ �1 ZResidential Value of Work 451 ' Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address -Te-"o� l_ . .b na Contractor's Name Telephone Number �C�� ✓`� Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance C ck one: [VI 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 must be on file. Permit Request(check box) [�Re-roof(stripping old shingles) All construction debris will be taken to -OAI� - T ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Hom Improvement Contractors License is required. SIGNATUR . ,, Q:Forms:expmtrg Revise071405 �aFtME, Town of Barnstable ti Regulatory Services RAMSrABLE, v Mnss. Thomas F.Geiler,Director �p 16J9. ♦0 PFDMA�p Building Division. Tom Perry, Building Commissioner 200 Main Street, Iiyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, -JW f)Z LA rib ,as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authonw by this building permit application for. SC-R) G ohs «q (Address of Job) Z G Sijqafure of Owner Date J-e-woe- Lob Print Name Q:FORM&OwNERPERMIS SION The Commonwealth of Massachusetts ` Department oflndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual).. j ` & Address: �' 0. 9oN-J12; I City/State/Zip: ►1 O�.�p(�) Phone Are you an employer? Check the-appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I mployees(full and/or part-time).* have hired the sub-contractors 6. ❑ New construction 2. v I am a sole proprietor or pmmer- listed on the attached sheet. 1 7. ❑ Remodeling ship and have no employees These sub-contractors have 8: ❑ Demolition working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions myself.[No workers' comp. c. 152, §1(4),and we have no 12.ffRoof repairs insurance required.] t employees. [No workers' 13 ❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information' t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tContracturs that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. I am an employer that Is providing workers'compensation Insurance for my employees. Below is the policy and,yob 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 secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500,.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains andpenalties ofperjury that the information provided abov is true and correct. Si —�afore: Date: a I Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: Board of Buildin � l� o�`ivuraaac�iu g Regulations and Standards HOME IMPROVEMENT License or registration valid for individul u CONTRACTOR Re Istratio`n: before the expiration date. If found re use only=._24310 Board of Building turn to: 007 g Regulations and Standards place One Ashburton i�dual Rm 1301 ames Curley _ - I Boston,Ma.02108 Imes Curley 17 Fuller Rd. -� mterville,MA 02632 �--+ Administrator Not valid without signa re I I Job: Amy Rose Sager 58 Seth Goodspeed's Way TradeMark Professionals Osterville, MA 02655 Existing Basement Mike Baker 78 Bridle Path Bulkhead Marstons Mills, MA 02648 508-717-2982 trademarkprof@comcast.net 880E 880E ca (V a � M i c'7 _ f _. tea tl] �= o i w - � I r S 1 I I O I I • ( I L w 0906 i i t SMOKE �-r BAR SSTABLE SUILDING DEPT. DAI` 1 99oE FIRE DEPARTMENT CA;'L Job: Amy Rose Sager BOTH SIGNATURES ARE REOu`iREO FOR PE,9�i.'.'Tt'ii"J`. 58 Seth Goodspeed's Way TradeMark Professionals" Osterville, MA 02655 Proposed Finished Basement Mike Baker 78 Bridle Path Marstons Mills, MA 02648 1 508-717-2982 trademarkprof@comcast.net egos OEM Mcmq 9 ai a °Bees° es 1�ses% _ 00 g FD a00 ciCCO Shower — �� 1 M1 J '9C."89oe 118/b 0-19 Bathroom PIZ O00 "$/ L- � ch 1 st Floor Level Hallway from Kitchen to the Ilb/£ L-1£ r- Garage,Backyard&Basement 99os i1) co C— \ 1 � `n m .S 10 6 N V Closet/Storage 899E Walls 2x4 w/ PT Plates RAQ FGL INS w/Vapor Barrier �Z - \C� 1/2" Drywall on Ceilings & Walls i HRV Air Exchanger FanTech Model #VH704 � � NOQ SS Open Door Way EO Egress Window WellCraft Model#2062 w/cover 6-1 UM _ Finished Area 1040sq' Egress ^ Louvered Door& j Window Zo "8/5 £ 't' _I Living Room o) ` , Open Vents For Furnace LO Office 118/£ 9-Ib 6 LO N , O •— N 10� � Strorage/Utility Room - a 1Jp �.��c«c� ✓" w