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Town of Barnstable Building
t Post This Card So That it is Visible From the Street-Approved Plans Must be Retained on Job and this Card Must be Kept
BAMSTAB
� MARL Posted Until Finial Inspection Has Been Made. Permit
1639 p��
D►��t Where a Certificate of Occupancy is Required,such Building shall Not be Occupied until a Final Inspection has been made.
Permit No. B-20-647 Applicant Name: WILLIAM E FARRINGTON Approvals
Date Issued: 03/16/2020 Current Use: Structure
Permit Type: Building-Alteration INTERIOR Work Only- Expiration Date: 09/16/2020 Foundation:
Residential Map/Lot: 117-180-2-AG Zoning District: SPLIT Sheathing:
Location: 39 BLDG E UNIT T10 TOWER HILL ROAD,OSTERViLLE Contracto`� rY Na e-,,,FARRINGTON BUILDING & framing: 1
Owner on Record: DWARNICK,SUSAN L f REMODELING INC.
2
Address: 1603 VARNUM STREET NW _._ ,Contractor License: 115356
Chimney:
WASHINGTON, DC 20011 Est. Project Cost: $30,000.00
Description: REMODEL KITCHEN, MOVE LAUNDRY TO 2ND FLOOR EXPAND Permit Fee: $203.00 Insulation:
SHOWER IN 2ND FLOOR BATHROOM Fee Paid 5 203.00 Final:
Project Review Req: - � Date:/ 3/16/2020
Plumbing/Gas
Rough Plumbing:
nUfficial Final Plumbing:
This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after.lssuan
All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. Rough Gas:
All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes.
This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the Final Gas:
work until the completion of the same. V
Electrical
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this,permit.
Minimum of Five Call Inspections Required for All Construction Work: ff Service:
1.Foundation or Footing
2.Sheathing Inspection _ Rough:
3.All Fireplaces must be inspected at the throat level before firest flue lining is installed
Final:
4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection
5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough:
6.Insulation
7.Final Inspection before Occupancy Low Voltage Final:
Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health
Work shall not proceed until the Inspector has approved the various stages of construction.
Final:
"Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A).
- Fire Department
Building plans are to be available on site
Final:
All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT
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Fi rst j Property
M A N A G E M E. N T
167 Lovell's Lane Telephone 508.420.0299
Marstons Mills, Ma. 02648 www.fpmcapecod.com
January 3, 2020
To Whom it May Concern
Farrington Builders has permission to do remodeling and repair work at 39 Tower Hill Rd,
Osterville.
Andrew Witter CMCA, AMS, ARM
President, First Property Management
Managing Agent for The Village Sq, North Condominium Association
I
A��® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYY1)o7/12/2o1s
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
ELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
EPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT NAME: Michelle Wolf
HUB INTERNATIONAL NEW ENGLAND LLC PHONE (781)792-3298 FAX
No ac
ADDRESS: Michelle.wolf@hubintemational.com
600 LONGWATER DRIVE INSURERS AFFORDING COVERAGE NAIC A
NORWELL MA 02061 INSURER A: AIM MUTUAL INS CO 33758
INSURED INSURER B:
FARRINGTON BUILDING & REMODELING INC INSURERC:
INSURER D:
17 JAN SEBASTIAN DRIVE SUITE 13 INSURER E:
SANDWICH MA 02563 INSURERF:
COVERAGES CERTIFICATE NUMBER: 424433 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP
LTR POLICY NUMBER MMIDD/YYYY MM/DD/YYYY LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
CLAIMS-MADE OCCUR DAMAGE TO RENTED
PREMISES Ea occurrence)
ccurrence $
MED EXP(Any one person) $
N/A PERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
tANY
JECT LOC PRODUCTS-COMP/OP AGG $
: $
E LIABILITY COMBINED SINGLE LIMIT $
Ea acc dent
TO BODILY INJURY(Per person) $
NED SCHEDULED AUTOSN/A BODILY INJURY(Per accident) $
NON-OWNED PROPERTY DAMAGE
AUTOS AUTOS Per accident $
$
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $
DED I I RETENTION$ $
WORKERS COMPENSATION /� STATUTE ERH
AND EMPLOYERS'LIABILITY Y/N
ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000
A OFFICERIMEMBEREXCLUDED? N/A NIA NIA AWC40070322682019A 03/14/2019 03/14/2020
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000
If yes,describe under
DESCRIPTION OF OPERATIONS below I I E.L.DISEASE-POLICY LIMIT $ 500,000
N/A
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay
claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts.
This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the
issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification
Search tool at www.mass.govAwd/workers-compensation/investigations/.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
i
Town of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS.
0 Main Street
A`UTo 3�0
HORIZED REPRESENTATIVE
Hyannis MA 02061 L
Daniel M.'Cr y,CPCU,Vice President—Residual Market—WCRIBMA
@ 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
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Commonwealth of Massachusetts
®1 Division of Professional Licensure
Board of Building Regulations and Standards
Const`I&QU isor
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CS-061665 _ Ealpires: 07/01/2021
WILLIAM E F#RRINGTON, r
17 JAN SEBASTIAN.DR SUITE 13 R
SANDWICH 111rA�02663.1
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Commissioner
f icy of Consurn,Ap
Affairs and .
Business k
Re, ulation (OCABR, ` f
Registration Complain �..
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+� Rent FARRINGTON BUILDING S REMODELING,INC.
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33 BOARDLEY RD.
^4•dState ZiP SANDWICH,MA 02563
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Commonwealth of Massachusetts
® Division of Professional Licensure
Board of Building Regulations and Standards
Const` 04prvisor
CS-061665 ,pires: 07/01/2021
WILLIAM E FjlMl
17 JAN SEBABTIAN E 3
SANDWICH 11fiLj 0266'
Commissioner
Office of Consume
Affairs and .
Business
: .Regulation.(0CABR,
` HIC Registration Complaints:
RegUtMUOn 3 116356
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Nam' nt FARRINOTON BUILDING d REMODELING,INC.!
43' W 4(AM FARRINGTON
33 BOARDLEY RD.
I• ^M.State Zip SANDWICH,MA MM
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Lauzon, Jeffrey
From: Lauzon, Jeffrey
Sent: Tuesday, March 10, 2020 3:36 PM
To: 'FARRBLDG@COMCAST.NET'
Cc: Lauzon, Jeffrey
Subject: ViewPermit, Permit No:TB-20-647
Applicant,
Please be advised that the above application has been reviewed and the following is noted:
1) No framing or floor plans submitted.
The application is denied pending the submission of framing and floor plans.And, if aggrieved by this notice;you may
appeal to the Building Appeals Board within 45 days in accordance with M.G.L. c. 143 § 100.
Respectfully,
Jeffrey Lauzon
Chief Local Inspector
(508) 862-4034
ieffrey.lauzon61town.barn stable.ma.us
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o� 'Owti •QII=DING DEP T �, �
O Application Number.......4v.- .0.. .......................
FEB 2 s 2020
snxxsreaE,116� 203 too
e� fiQVv v tea- �,:� : ..................................Other Fee,.......................
iOrEb �� rAQSLE PenmtFee.....
TotalFee Paid............................................................... ......
TOWN OF BARNSTABLE Permit Approval by..
Y........................On... �61 .........
BUILDING PERMIT `/
Map..../•! .............Parcel....�O..� 2,��
... ............... ............. ............
APPLICATION
Section 1 — Owner's Information and Project Location -
Project Address w Z 1y �i ?cage lJ5�11-C,
Owners Name v 1�1,11-f SCANNED
Owners Legal Address y �vc�r�—�i�✓�� d�l�sr L T/o MAR 16 2020
City 6Z51A---ry Ile-- State 1010� zip 0 Z4,�—
Owners Cell # E-mail
Section 2 —Use of Structure
Use Group ❑ Commercial Structure over 35,000 cubic feet
❑ Commercial Structure under 35,000 cubic feet
❑ Single/Two Family Dwelling
Section 3 — Type of Permit
❑ New Construction ❑ Move/Relocate ❑ Accessory Structure ❑ Change of use
i
❑ Demo/(entire structure) ❑ Finish Basement ❑ Family/Amnesty ❑ Fire Alarm
Rebuild ❑ Deck Apartment Sprinkler System
❑ Addition ❑ Retaining wall ❑ . Solar
j ❑ Renovation ❑ 'Pool ❑ Insulation
Other—Specify
Section 4 - Work Description
A'/y.(�GQ �y C9d
Last updated 11/15/2018
Application Number....................................................
Section 5—Detail
Cost of Proposed Construction �✓G Square Footage of Project
Age of Structure Dig Safe Number.
# Of Bedrooms Existing Total# Of Bedrooms (proposed) y
110 MPH Wind Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist ❑ Design
Section 6—Project Specifics
Wiring ❑ Oil Tank Storage ❑ Smoke Detectors
'}A AA,:){?
Plumbing ❑ Gas ❑ Fire Suppression
❑ Heating System ❑ Masonry Chimney ❑Add/relocate bedroom
_ I
Water Supply 0 Public ❑ Private
Sewage Disposal ❑ Municipal ❑ On Site
Historic District ❑ Hyannis Historic District ❑ Old Kings Highway
Debris Disposal Facility: I am using a crane ❑ Yes ❑ No
Section 7—Flood Zone
Flood Zone Designation
Within or adjacent to a wetland, coastal bank? Yes ❑ No E'
Section 8—Zoning Information
Zoning District Proposed Use Lot Area Sq. Ft.
Total Frontage Percentage of Lot Coverage #of Dwelling Units (on site)
Setbacks Front Yard Required Proposed
Rear Yard Required Proposed
Side Yard Required Proposed
Has this property had relief from the Zoning Board in the past? ❑ Yes ❑ No
Last updated: 11/15/2018
i
' 1
Application Number...........................................
Section 9- Construction Supervisor
Name Lt/ zi/2" Telephone Number
Address City S � State �'� Zip D 2,�3
License Number GS� �� 5 License Type Expiration Date 7/'zz/
Contractors Email 114, Cell # -�;O S,S��S—�aa
I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780
CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and
documentation required by 780 C d the Town of Barnstable.Attach a copy of your license.
F
Date
Signature z� �d
Section 10—Home Improvement Contractor
I y "
Name �0P' /�"e-w%eielephone Number
Address City �s'.�.��c State�_Zip ZS 3
Registration Number 5-'3 5" Expiration Date 4�/�
I understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780
CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and
documentation required by 780 C an the Town of Barnstable.Attach a copy of your H.I.C...
Signature Date ���
Section 11 —Home Owners License Exemption
Home Owners Name:
Telephone Number. Cell or Work Number
I understand my.responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780
CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and
documentation required by 780 CMR and the Town of Barnstable.
Signature Date
APPLICANT SIGNATURE
°ignaWre Date
Prim`Name Telephone Number
E-mail hermit to:
Last updated: 11i15n018
Section 12 —Department Sign-Offs
Health Department ❑ Zoning Board(if required) ❑
Historic District ❑ Site Plan Review(if required) ❑
Fire Department ❑
Conservation ❑
For commercial work,please take your plans directly to the fire department for approval
j
Section 13— Owner's Authorization
� I
I, as Owner of the subject property hereby
authorize to act on my behalf, in all !
matters relative to work au o ' d by this building permit application for:
�-
(Address of j ob)
Signature of Owner date t
Print Name
Last updated: 11/15/2018
Town of Barnstable Building*--,
t Post This Card So That it is Visible From the Street-Approved Plans Must be Retained on Job and this Card Must be Kept
• EMWWABLK
.`fig Posted Until Final Inspection Has Been Made. Permit �I
059.� Where a Certificate of Occupancy is Required,such Building shall Not be Occupied until a Final Inspection has been made.
Permit No. B-20-646 Applicant Name:
Approvals
Date Issued: 02/28/2020 Current Use: Structure
Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 08/28/2020 Foundation:
Location: 39 BLDG E UNIT T10 TOWER HILL ROAD,OSTERVILLE Map/Lot: 117-180-ZAG Zoning District: SPLIT Sheathing:
Owner on Record: DWARNICK,SUSAN L Contractor Name: Framing: 1
Address: 1603 VARNUM STREET NW Contractor License: 2
WASHINGTON, DC 20011 Est. Project Cost: $4,000.00 Chimney:
Description: SIDING, REPAIR LEAK AROUND CHIMNEY, REPAIR ROTTEN WOOD Permit Fee: $35.00
Fee Paid) $35.00 Insulation:
Project Review Req:
Dat/e� 2/28/2020 Final:
/ / Plumbing/Gas
Rough Plumbing:
...__ ,,____. \Building Official
Final Plumbing:
This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after,issuance.
All work authorized by this permit shall conform to the approved application and thetapproved construction documents for which this permit has been granted. Rough Gas:
All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes.
This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the Final Gas:
work until the completion of the same. ,
Electrical
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit.
Minimum of Five Call Inspections Required for All Construction Work: / Service:
1.Foundation or Footing /
2.Sheathing Inspection Rough:
3.All Fireplaces must be inspected at the throat level before firest flue lining is installed
4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final:
5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough:
6.Insulation
7.Final Inspection before Occupancy
Low Voltage Final:
Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health
Work shall not proceed until the Inspector has approved the various stages of construction.
Final:
"Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A).
Fire Department
Building plans are to be available on site
All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT / Final:
. `mow R
Application number..... ................6...6
Fee ...... .................................................................
s AM Building Inspectors Initials.................
DateIssued.................................................................
Map/Parcel....... 7� 8o .a G:. . .1.... .... ......................
TOWN OF BARNSTABLE
EXPEDITED PERMIT APPLICATION: SCANNED
ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION
PROPERTY INFORMATION
Address of Project: CJiZr :O / .
NUMBER STREET VILLAGE
Owner's Name: Phone Phone Number
Email Address:41J"c-wi 0 Cell Phone Number 2-d
Project cost$ Check one Residential CO Commercial
OWNER'S AUTHORIZATION
As owner of the above property I hereby authorize �4
to make application for a building permit in accordance with 780 CMR
Owner Signature j��-�� w�� Date:
TYPE OF WORK
Siding ❑ Windows (no header change)# ❑ Insulation/Weatherization
❑ Doors(no header change) # Commercial Doors require an inspector's review
❑ Roof(not applying more than 1 layer of shingles) _
Construction Debris will be going to 3- —
CONTRACTOR'S INFORMATION
Contractor's name y�
f
Home Improvement Contractors Registration(if applicable)# S l (attach copy)
Construction Supervisor's License# /4e� (attach copy)
Email of Contractor y,r��/� Vic, Phone number-5":
ALL PROPERTIES THAT HAVE RUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN
APPLICATION NUMBER............................................................
*For Tents Only*
Date Tent(s)will be erected Removed on number of tents total
Does the tent have sides?Yes No (If yes please attach floor plan with exits marked)
Dimensions of each Tent X X X
Additional tent dimensions can be attached on a separate piece of paper.
Purpose of Event
1t�,,J'Check"one: this event is a: for profit non-profit event
Check one: Food served Yes No
Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s)of each tent
Fuel source being used LP tank 201bs. or> Yes No ,if yes, a gas permit is required.
Natural Gas Yes No ,if yes, a gas permit is required.
If food is being served at your event please obtain a Health Department approval between the hours
of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval
*WOOD/COAL/PELLET STOVES
Manufacturer# Model/I.D.
Fuel Type Testing Lab
Offsets from combustibles: front back left side right side
HOMEOWNER'S LICENSE EXEMPTION
Homeowner's Name:
Telephone Number Cell or Work number
I understand my responsibilities under the rules and regulations for Licensed Construction
Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand
the construction inspection procedures,specific inspections and documentation required by 780
CMR and the Town of Barnstable.
Signature Date
i
APPLICANT'S SIGNATURE
Signature Date
All permit applications are subject to a building official's approval prior to issuance.
APL The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le 'bl
NaTT16 (Business/Organization/Individual):
Address: / /
City/State/Zip: ;VVIi` 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 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
working for mein any capacity. employees and have workers' 9. ❑Building addition
[No workers'comp. insurance comp.insurance.t
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 I.❑Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees. [No workers' 13.❑Other
comp. insurance required.]
*My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
=Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
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 er the pai and pe Ities of perjury that the information provided above is true and correct
Signature: Date: y
Phone#:
Official use only. Do not write in this area,to be completed by city or town ofciaL
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#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
ofthe foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required"
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificates)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
j (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel.#617-727-4900 ext 406 or 1-877-MASSAFE
Revised 4-24-07 Fax#617-727-7749
www.Mm.gov/dia
L '
Application number......... .'.�:1......
.. ..9..I�.7&
4WN OF 6I4RNSTA91�E Fee ..................tl(P..0..:..................................
KAM 02 Building Inspectors Initials........... ..15..................
Date Issued.:.... .a,..... ..... ...............................
Map/Parcel........ ........r. o...::.�.A:G.....
TOWN OF BARNSTABLE
EXPEDITED PERMIT APPLICATION:
ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION
PROPERTY INFORMATION
Address of Project: c3 /� �e/�t
NUMBER STREE VILLAGE
Owner's Name: Phone Number 0-0 z--��z--c� d�
Email Address: s��C�r/y�-`l�c� Cell Phone Number
Project cost$ Z�OO� Check one Residential / Commercial
OWNER'S AUTHORIZATION
As owner of the above property I hereby authorize
to make applications for a building permit in accordance with 780 CMR
Owner Signature:�^- I CII� Date:
TYPE OF WORK
❑ Siding �aj Windows(no header change)# Insulation/Weatherization
❑ Doors(no header change)#�_ Commercial Doors require an inspector's review
❑ Roof(not applying more than 1 layer of shin s)
Construction Debris will be going to
CONTRACTOR'S INFORMATION
Contractor's name �►
Home Improvement Contractors Registration(if applicable)# ��l � - (attach copy)
Construction Supervisor's License# G$ '��/��� (attach copy)
Email of Contractor IbI1 d Phone number' 5�
ALL PROPERTIES THAT HAVE STR CT IRES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN
A uicTnoir nicTRlrr vn11 Am ICT nRTAiiu uicTnRir ADDRnVA1 RFFnRF A DFRM/T/'AN RF ICU IFn
1 .
APPLICATION NUMBER............................''...........::............O:
*For Tents Only*
Date Tent(s)will be erected Removed on number of tents total
Does the tent have sides?Yes No (If yes please attach floor.plan with exits marked)
Dimensions of each Tent X X X
Additional tent dimensions can be attached on a separate piece of paper.
Purpose of Event
Check one: this event is a: for profit non-profit event
Check one: Food served Yes No
Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s)of each tent
Fuel source being used LP tank 20 lbs. or> Yes No , if yes,a gas permit is required.
Natural Gas Yes No ,if yes,a gas permit is required.
Iffood is being served at.your event please obtain a Health Department approval between the hours
of 8:00am-9.30 am or 3.30 pm-4:30pm. Commercial events may require Fire Department approval.
*WOOD/COAL/PELLET STOVES
Manufacturer# Model/I.D.
Fuel Type Testing Lab
Offsets from combustibles: front back left side right side
HOMEOWNER'S LICENSE EXEMPTION
Homeowner's Name:
Telephone Number Cell or Work number
I understand my responsibilities under the rules and regulations for Licensed Construction
Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand
the construction inspection procedures,specific inspections and documentation required by 780
CMR and the Town of Barnstable.
Signature Date
1
5. APPLICANT'S SIGNATURE
Signature Date �( G�
All permit applications are subject to a building official's approval prior to issuance.
1
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111 -
www.mass.gov/duz
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le 'bl
Name(Business/Organization/Individual): y !�
Address: 17 0 C-
City/State/Zip: 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
employees(full and/or part-time).* have hired the sub-contractors 6. [3 New construction
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
workingfor me'in an capacity. employees and have workers'
Y P h'• = 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 a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees. [No workers' 13.[1 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.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance-for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: 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 certi er the d penalties of perjury that the information provided above is true a d correct.
Signature: Date: Z ��
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#:
i
Y
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificates)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington.Street
Boston,MA 02111
Tel.#617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 4-24-07
www.mass.gov/dia
l
Office of Consur �'
Affairs and
Busi-ness +
regulation (OCABR)
hilC Registration Complaini`I,
s Registration# 115358 t
Reghgranl FARRINGTON BUILDING&REMODhl'
Name WIL41AM FARRINGTON
Address 33 BOARDLEY RD. `
City.State Zip SANDWCH,MA 02563
=xpirstion Date 06/0&2020 .
n plalnts Details
'eomplamta found for this registrant.
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Village Square North Condominiums
Architectural Review Committee Request
Unit:T10-39 TOWER HILL RD.#T10 Account: 120.00-Dwarnick,Susan
Requested on: 10-21-2019
Request* 1,010
Approved
Summary:Windows
Description:
- We plan on replacing all the windows,the slider-downstairs and the door to the upstairs deck with Anderson 400
Series products. We are going with the new construction windows and will complete the work before the painting on
T-10 begins(whatever option is selected). Of course the light pattern(the faux panels)will match and will be
installed between the double panes of the window so as not to impact the cleaning process.
Sue, You need permission from the Board of Trustees for the windows and doors. The windows and doors must
be the same size,color and design as the existing.
Number of request 1,010.00
Printed on Friday, November 29 2019 Page 1 of 1