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HomeMy WebLinkAbout0109 WEST BAY ROAD ACTIVE Town of Barnstable of rHF rq� Regulator ' Services o Thomas E. Geiler,Director Building Division IIAlMIN L_ v 1S �g Tom ferry,Building Commissioner 0 MA��` 200 Main Street, Hyannis,MA 02601 Office: 509-862-4038 ax: S08-790-6230 Approved: Fee: o?s Permif#: , HOME OCCUPATION REGZSTRADON D ate,_ Name:_�p��� �O0C11 PhoneAddress: ( v . Ly_' I 'f -x 1 W Village:_ ' 0 i l I P Name of Business: Cl- ( V �o• �'��U i�1'�11Y Type of Business: ems 0 I T 1/`A Map/Lot: I b 1d I INTENT: It is the intent of this section to allow the residents.of the Town of Barnstable to operate a home occupation within single family dwellings, subject to the provisions of Section 4-1.4 of the Zoning ordinance, provided that the activity shall not be discernible from outside the dwelling: there shall be no increase in noise or odor;no visual alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes; and no increase in air or groundwater pollution. After registration with the Building Inspector, a customary home occupation shall be permitted as of right subject to the following conditions: • Fhe activity is carried on By Uie'permarient resident of a singe y residchdA dweffiiig Unit,-oca e that dwelling unit. • Such use occupies no more than 400 square feet of space; • There are no external alterations to the dwelling which are not customary in residential buildings, and there is no outside evidence of such use. • No traffic will be generated in excess of.normal residential volumes. • The use does pot involve the production of offensive noise, vibration,smoke,dust or other particular matter,' odors, electrical disturbance,heat,glare,humidity or other objectionable effects. • There is no"storage-or:use of toxic or-hazardou$materials, or flammable or explosive materials,in excess of normal household quantities. • Any need for parking generated by such use shall be meE.on the same lot containing the Customary Home Occupation,and not within the required front yard. • There is no exterior storage or display of materials or equipment. • .There is no commercial vehicles related to the Customary Home Occupation, other than one van or one pick.p-kueknot-to:.cxceed•one tor�,capacity, and one hailer not to exceed 20 feet in length and not to — ex=d 4 tires,parked on the same lot containing the Customary Home Occupation. • No sign shall be displayed indicating the Customary Home Occupation. • If the Customary Home Occupation is listed or advertised as a business, the street address shall not be included. • No person shall be employed in the Customary Home Occupation who is not a permanent resident of the dwelling unit . I, the undersign have read and agree with the above restrictions for my home occupation I am registering. YOU WISH TO OPEN A BUSINESS. For Your Information: Business certificates (cost$30.00 for 4 years). A business certifica a ONLY REGISTERS YOUR NAME in town (which you must do by M.G.L.-it does not give you permission to operate.) Business Certificates ar available at the Town Clerk's Office, 1°`FL., 367 Main Street, Hyannis, MA 02601 (Town Hall) . DATE: r', /� Fill in please: APPLICANT'S YOUR NAME/S:,, r� > BUSINESS YOUR HOME ADDRESS: 9 I JasT' z TELEPHONE # Home Telephone Number s6f' NAME OF CORPORATION: ' NAME OF NEW BUSINESS 5oujr 1 i• f3u TYPE OF BUST' ESS 0 r IS THIS A HOME OCCUPATION? � . Y-E!E NO ADDRESS OF BUSINESS L t 1 we { z 0S r- 41"' MAP/PARG L NUMBER 0'� I (Assessing) When starting a new business there are several things you must do in order to be in compliance I ith the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You UST GO TO 2QPJV1aih_St. - (corner of Yarmouth Rd. & Main Street) to make sure you have the appropriate permits and licenses required to legally o IM" N FbVMCOUPATION 1. BUILDING CO I SIIn ER' OFF �aanyerTit I RULES AND REGULATIONS. FAILURE TO This individ al h s fnfor requirements that pertain to this type siness�OMPLY MAY RESULT IN FINES. Au oriz Sin COMMENT Utz 2. BOARD OF HEALTH This individual h. s en infor` V�f� he IEreq, it ments that pertain to this type of business. Authorized i nature** COMMENTS: 3. CONSUMER AFFAIRS (LICENSING.AUTHORITY) This individual.ha 'een)nfefmed of the 'c5ensing requirements that pertain to this type of business. Authorized ignature** COMMENTS: Town of Barnstable *Permit#ai!5�07a&� + / ~� Expires 6 months from iss'e date Regulatory Services Fee • , Thomas F.Geller,Director Building Division Tom Perry, CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.tovm.barnstable.ma.us Office: 508-8624038 Fax: 508-790- 0 EXPRESS PERMIT APPLICATION - RESIDENT Not Yalid without Red X-Press Imprint ap/parcel Number o Jperty Address 1a �0 f Residential Value of Work „0 Minimum fee of$25.00 for work under $6000.00 n+ner's Name&Address Gv�s-74 ��a �ntractor s I�ame l ,fX / � / ���r' r Ui✓ ! / r ��451 � M��4 1Wl� ephone ATumbez ome Improvement Contractor License#(if applicable) CS 15116 z Arc. 41 111,5-1&,50 ]Workman's Compensation Insurance. -PRESS PERMIT . Check one: B� ❑ I am a sole proprietor APR 2 7 2�07 ❑ I am the Homeowner I have Worker's Compensation Insurance TOWN OF BARNSTABLE surance Company Name !�4 N r.c�� S�G�1 ✓lf� _orkman's Come Policy# opy of Insuiance Compliance Certificate must be on file. ;writ Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side )replacement Windows/doors/sliders. U-Value LP, (maximum.44) WkiCre required: ksuancc of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Pro �''D'Letter of Permission. A op AeHome ImproverpCantractors License is required. T � fGItATURE: AA V Forms:expmtrg ;7 mse061306 �o��� ' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111' wtvw.m. ass.gov/dia ' Workers -Compensation Insurance Affidavit: Builders/Contractors/Electridans/Plumbers Applicant Information / Please Print Le 'bl Name(Business/OrganizatiowTndividual): . Address O17 City/State/Zip: /lit Phone.#: jog';vI 7 S`'a��' Ar you an employer?Check theappropriate bog: :Type of project(required):. 1, am a employer' O 4. [] I am a general contractor and I 6 New construction . employees (full and/or part-time),* • have hired the stab-contractors listed on the'attached sheet. 7. ❑Remodeling 2.❑ I am a'sole proprietor or partner- These sub-contractors have ship and have no employees 8. ❑Demolition: w employee;;and have workers' ❑ working for me in any capacity. $. 9. Building addition [No workers' comp.insurance comp.insurance. 5. [] We are a corporation and its 10.❑Electricalrepaixs or additions required.] officers have exercised their 11.❑Plumbing repairs or additions ' 3.❑ 1 am a homeowner doing ill-work . myself,[No workers' comp. right of exemption per MGL 12.E]Roof repairs insurance.required.]t c. 152, §1(4),and we have no 13.❑ Other employees. [No workers' comp,insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t 11omeowners.who submit this affidavit indicating they are doing all work and then hire outside contractors mutt submit anew affidavit indicating such. #Contractors that check this box must attached sa additional sheet showing the name of the dub-contractors and state whether ornot those entities have . employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. anm o mloyees. Below is.the policy and job site. .1 information. Insurance Company Name: Policy#or Self-ins.Lic.#: Ui C 7 /6yt Expiration Date: Q / i6 lob Site Address: 0 S �� ' City/State/Zip: .Attach a copy of the workers' compensa ion policy.declaration page'(showing the policy number and expiration date). Failure•to secure coverage as required tmder Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine tip to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORKDRDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the-Office of Investi ations of the DIA for insurance covera a verification. I•do hereby eerti uncleLthepoi sand penalties of perjury that the information prgvided above, true and carrect e: - Date: Si tur Fm se only. Do not write in this area, to.be completed by,city or town official own: ' ,Permit(License# Authority(circle one): of Health 2.Building Department 3,City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 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 hue, 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('n states"Neither the commmondvealth nor any of its political subdivisions shall enter into any contract for.the performance of public-work until acceptable evideaee•ofcornplia*v{ith:tlie in=ance' requirements of this chapter have been presentedto the contracting authority.." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,it necessary,supply sub-contiactor(s)name(s),address(es)and phone number(s)along with their cerdficate(s)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 regiurea 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. Anew affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related fo 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 COMMODWW&of M=aPhUS4tts D%WtMent of IudusWW Aeta dints P.M"of InVeSUPROW. 600 W gte i Stt'eet BWQn.,.MA 02111 . . Tel.#617-727-00 ext 40,6 or 1-877-MASWE Fax#617-727-7749 Revised 11-22.06 . W .m=.80v'fdi0 1 T own of Baitnstable. Regulatory Services 9 MASS.Ate' Thomas F.Geiler,Director �AlfDMp�A`� Building Division Tom Perry, Building Commissioner 200 Main Street Hyannis,-MA 02601 www.town,barnstable.ma.us I Office: 508-862-403 8 Fax: 5 08-790-6:2 3 0 Property Owner Must Cotn' plete and Sign This Section If Using A Builder as Owner of the subject prope rty- hereb authorize`UQ��e UUa sr.vJ pfv,� `/^ 4 Am �' Y i /�Fe�7u15� � � ��� �t'o ac o my behalf, in all matters relative to.work authorized by this building permit application for . AV /* (Adores of Job) Sign ature of Owner ate Print N=e O:FORT✓S:O�iT.�RP�,RN�I55IO2�' r7ro1nr» G,h ' �,s ✓ -W 111LDING RE �e • :'�� '"�g(OP+1�#OF� UCTION SUpEW t �,�' License: fi�NSTR 0g1653 .. .,M " kr Numbe7.w CS •: t; gtrthdate 091301959 �;g1r a, 0918012008 fi 3f ss All t . " .. W ALTER NDER M M-1 75' s 40 ILEX H pbR xA� �r --_Gf.�_�y �&� �'�. �%eta _.__.._._---- --• l3oarJ o 13uig cgu auons and 5tand:u ds License or registration valid for individul use only _ — HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: 1 Board of Buildingliegulations and Standards RegistraUo�• 45832 One Ashburton Place 12tn 1301 Expiration<_:3/4/2009 Tr# 127455 Boston,Ma.021U8 �tl 'TYpe:: DBA; NORTH SIDE HOMF'IMRRO.V.E_MENT WALTER WARREN,J`R .il �- /rI' 40ALEXANDER DRY\ Not valid without signature YARMOUTHPORT, MA'02f75%' Administrator GRANITE STATE INSURANCE COMPANY 92252-0000 WC - 874-52-23 13102 ---------------------=----------------------- 013-66-0506-00 •= PENNSYLVANIA Mh ,,• • WALTER R WARREN JR. 40 ALEXANDER DR �� Member Companies of YARMOUTHPORT, MA 02675-0000 American International Group EXECUTIVE OFFICES: 70 PINE STREET, NEW YORK, N.Y. 10270 SEE NAME AND ADDRESS SCHEDULE - WC990610 I.D# MA UI : HUB INTERNATIONAL NEW ENGLAND LLC WORKERS COMPENSATION AND EMPLOYERS 437 STATION AVE LIABILITY POLICY INFORMATION PAGE SOUTH YARMOUTH, MA 02664-0000 INSURED IS PREVIOUS POLICY NUMBER INDIVIDUAL NEW OTHER WORKPLACES NOT SHOWN ABOVE:SEE NAME AND ADDRESS SCHEDULE - WC990610 ITEM 2 POLICY PERIOD 12:01 A.M.standard time at the insured's mailing address FROM 05/19/06 TO 05/19/07 ITEM 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to the work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident Bodily Injury by Disease $ SOO.000 policy limit Bodily Injury by Disease $ 100,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if.any, listed here: SEE ENDORSEMENT - WC200306A ITEM 4 The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Estimated Total Rate Per Estimated Classifications Code Number Remuneration $100 OF Re- Premium Annua 0 3 Year muneration n AnnualEl 3 Year SEE EXTENSION OF INFORMATION PAGE - WC7754 TAXES/ASSESSMENTS/SURC.HARGES $24 O(PENSE CONSTANT(EXCEPT WHERE APPLICABLE BY STATE) $284 MA MINIMUM PREMIUM $500 MA TOTAL ESTIMATED PREMIUM $$28 f indicated below, interim adjustments of premium shall be made: Semi-Annually El Quarterly Monthly DEPOSIT PREMIUM ENDORSEMENTS(FORM NUMBER) SEE ATTACHED FORM SCHEDULE - WC990612 )6/12/06 ASSIGNED RISK 66 Issue Date Issuing Office 7Authorized Representative WC 00 00 01 19967 IIVQI IRCrI'Q (1r)0V TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map /167 Parcel v l Application# a, `76 S Health Division Conservation Division Permit# Tax Collector Date Issued y 3 JOB Treasurer Application Fee ' <V .Ci Planning.Dept. Permit FeeZs �� Date Definitive Plan Approved by Planning Board t391316 Historic-OKH Preservation/Hyannis Project Street Address /0 9 (AJ PSf epC%y �U a Village Q � U, I/ Owner Ft-�'-r. 1�r K`-S Address l G� W��� a y g Telephone k, Permit Request 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 j6No On Old King's Highway: ❑Yes dlo 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 ! ry Total Room Count(not including baths):existing new First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑ Electric ❑Other cn� Cty ca:w Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑i existingQO new; size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: f Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use / /BUI/LDER INFORMATION Name�a��� l �/�'IM'M( r�itP G�� g"Vl ephone tNvuumVVber Address 4-'-o ��Q�vct' ���V-C License# C.S 0?1/G S3 Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO Gw^� �4��2G"�' `► SIGNATURE DATE 3!/.Z 2/02) �t FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED MAP/PARCEL NO. - ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION r ` FRAME INSULATION FIREPLACE ' ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL t FINAL BUILDING i DATE CLOSED OUT ASSOCIATION PLAN NO. i - i The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations A d 600 Washington Street Boston,MA 02111 ,• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'bl Name(Business/Organization/Individual): WA the- o ri.-/ 01 Address: /He -4 City/State/Zip: ` C1/ v �'�� Phone.#: 0 Are you an employer?Check the'appropriate bog: Type of project(required):. 1.71 I am a employer with � 4. ❑ I am a general contractor and I 6. El New construction . employees(full and/or!!:�F have hired the sib-contractors 2.ElI am a'sole proprietor 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 tY 9. ❑Building addition [No workers' comp.insurance comp.insurance. required.] 5. ❑ We are a corporation and its 10.0 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.❑ 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 subnrit 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. QQ Insurance Company Name: Policy#or Self-ins.Lic.#: C lJ C. p? S� '� Expiration Date: c5_L Job Site Address: `,Ly Q°a`r'` 05 City/State/Zip: � 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 of this statement maybe forwarded to the Office of Investigations of the bIA for insurance coverage verification. I do hereby certify nder t �e pains-an penalties ofperjury that the information provided above is true and correct. Si attue: — Date: Zo_�2 _ Phone 7 31257� 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): A.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions y 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 nr•.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-contiactor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies'(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or 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 io any business or commercial venture.: (i.e.a dog license or permit to bum leaves-etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,�- please do not hesitate to give us a call. The Department's address,telephone-and fax number: Tie Commonwealth of Massac vwtts Departmexnt of hidusWai A.ceitlents Office of Investigation 600 Washington Street Boston,MA Q2111 Tel. ext 406 or 1-977-MASSAFB Fax##617-727-7749 Revised 11-22-06 www mass.gQv/dia / E '.LV YT 11 V A y_l"JL AAW►-K RJ A V - ,r; "° REgulatory&rviees C ,* Thomas F.Geiler,Director loss $ 26g9. Building Division Tom.Perry,Building Commissioner. .200 Main Street, Hyannis,MA 02601 www.towrt.b arnstabl e.ma.us ice: 508-862-4038 Fax, 508-190-6230 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW -SUPPLEMENT TO PERMIT APPLICATION MGL c, 142Areq=es thatthe"reconstruction,alterations,renovation,repair,modernization, conversion, improve3nmt removal, demolition,or construction of an addition•to any pre-existing owner-occupied - bwlding containing at least one but not more than four dwelling units.or to Structures which•are adjacent to 1 mr.1 residence or bu>7ding be done by registered contractors,with certain exoeptions;al= with o+�er requirements- Type of work:_ Estimated Cost_ Xl Address.of'Work:. 6c S�f �/ �v' �'` , Oyyner's Name: Date of Application: OI L),rI.6 7 I hereby certify that: ' RegistratiQn.is not required for the following reason(&); ❑Work excluded by law FlJob Under$1,000 C]Building not owner-occupied ❑owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT FORK DO NOT HAVE ACCESS TO THE ARBITRATI03`IPROGRAM OR GUARANTY FUND UNDER MGL c, 142A. SIGNED UNDER PENALTIES OF PERJURY I her, apply for a permit as the agent of owner; Date Contractor S gna e. Registration No, OR Date Owner's Signature Q y pEes i rms:homeaffidzv Rev: 060606 °p'VHE ram, Town of Barnstable. ~ Regulatory Services ' Thomas F.Geiler,Director �'0le16 99- i3O� Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Properly Owner Must Complete and Sign This Section If Using A Builder I 1 rV as Owner of the subject roPenY .� P hereby authorize W� ! �rY to act on my behalf, in all matters relative to.work authorized bythis building permit application for: . lag w � 66-1 r �G (Address of job) SignatuYe of Owner Date Print Name Q TORM S:O WNERPERMIS S ION '• GRANITE STATE INSURANCE COMPANY 92252-0000 WC 874-52-23 13102 --------------------------------------------- 013-66-05o6-00 .-•.•. PENNSYLVAN I A WALTER R WARREN JR. 40 ALEXANDER DR aln Member Companies of YARMOUTHPORT, MA 02675-o000 American International Group i EXECUTIVE OFFICES: 70 PINE STREET, NEW YORK, N.Y. 10270 SEE NAME AND ADDRESS SCHEDULE - WC990610 I.D# MA I : - •• •. HUB INTERNATIONAL NEW ENGLAND LLC WORKERS COMPENSATION AND EMPLOYERS 437 STATION AVE LIABILITY POLICY INFORMATION PAGE SOUTH YARMOUTH, MA 02664-00o0 INSURED IS PREVIOUS POLICY NUMBER j INDIVIDUAL NEW OTHER WORKPLACES NOT SHOWN ABOVE:SEE NAME AND ADDRESS SCHEDULE - WC990610 ITEM 2 POLICY PERIOD 12:01 A.M.standard time at the insured's mailing address FROM 05/19/o6 To 05/19/07. ITEM 3 A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA j B. Employers Liability Insurance: Part Two of the policy applies to the work in each state listed in item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 100,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 100.000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE ENDORSEMENT - WC2003o6A ITEM 4 The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Estimated Total. Rate Per Estimated Classifications Code Number Remuneration $100 OF Re- Premium Annual 3 Year muneration Annual 3 Year SEE EXTENSION OF INFORMATION PAGE - WC7754 TAXES/ASSESSMENTS/SURCHARGES $24 EXPENSE CONSTANT(EXCEPT WHERE APPLICABLE BY STATE) $284 MA MINIMUM PREMIUM $500 MA TOTAL ESTIMATED PREMIUM 5828 If indicated below, interim adjustments of premium shall be made: I 11 Semi-Annually 11 Quarterly Monthly DEPOSIT PREMIUM ENDORSEMENTS(FORM NUMBER) SEE ATTACHED FORM SCHEDULE - WC990612 06/12/06 ASSIGNED RISK 66 4 Al Issue Date Issuing Of11ce 7Authorized Representative WC 00 00 O1 39967 INSURED'S COPY r Board"off Bui ing egns,and t�duSdPCld - License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration:\145832 Board of Building Regulations and Standards Exp_iration_, /4h2009 Tr# 127455 One Ashburton Place Rm 1301 �3 T, Tyvg-e DB Boston,Ma.02108 NTH SIDE HOME'flii1�20;V= y� LTER WARREN`;Jf2 € "1 `�L---i • LEXANDER DR.:����� MOUTHPORT,MA 0�2Fjy��'' Administrator Not valid without signature Vol , y_ License `CCSN,STRU695 CTIONS . rf" 091,E 53 Nutnbkr CS• . Birt d-RT, 3E}11959 aE— kt ' Ri�stricL .� - qll WALTER R WARR• JR i" V�.J i.40 AL�EXANDEfR tov /fie ova Re�nvv� 'c lose- >vO•v l001 �P4ir &Jot I Alfnit pWe or NA, t" A0 4 tj eaA�' - cA 141 sty 0I I I I All�l aid ' �e� et #fie t dVfA I I � I � I I � � ► I i I � I I I + I Q c4t "w'�S c�itwfl , � Ifrd I I I ll .gyp { , ' ► j o w� E►I 6.9Y f m-t`, ► � I I I I I I , � , I + I ! I ► I I ' � ! � ' I � I I I I I I I ► I I i I I � ► � ' I � j I i ' � � ' �I { Ile Ale i ► I � ► I ► I � I i I I I � � � I • � I I i I I I � + 1 � 1 I I I , ■ ��0� ■ ■ ■ N ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ .0 .� � . . I . -r, 6 Town of Barnstable *Permit# 0060 93 Expires 6 months from issu Regulatory Services' Fee Thomas F. Geiler,Director Ok /012vlo, Building Division r& m Tom Perry,CBO, Building Comissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address 'o 1 w if.!�+ R J 0,,54-Cfv M 4b [Residential Value of Work Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Contractor's Name Telephone Number —j q V_4g-Q) Home Improvement Contractor License#(if applicable) I � Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Che one: X-PRESS PERMIT am a sole proprietor ❑ I am the Homeowner O C T 19 2006 ❑ I have Worker's Compensation Insurance Insurance Company Name TOWN OF BARNSTABLE Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. ;Home vement tractors License is required. SIGNA Q:Forms:expmtrg Revise071405 i i aME Tp� Town of Barnstable ti Regulatory Services 9 MASS '$; Thomas F.Geiler,Director &639. Building Division. Tom Perry, Building Commissioner 200 Main Street, Iiyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Mier Must Complete and Sign This Section If Using A Builder I, � i� ,as Owner of the subject property hereby authorize �U.�Y VC�S `�N-1 UC to act on my behalf, in all matters relative to work authorized by this building permit application for. (Add s of Job) (3 I9 a0 %natur-e-oT Owner Date Print Name Q TORM&OWNERPERMISSION I he Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations 600 Washington Street ` Boston, M4 02111 www.mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Address: P. O . x 63 1 City/State/Zip: - 4MRIA OZUQ hone#: cl u -49TU 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 loyees(full and/or part-time).* have hired the sub-contractors 6• ❑ New construction 2. I am a sole proprietor or partner- listed on the attached sheet t 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 11.❑ Plumbing repairs o-• additions myself.[No workers' comp. c. 152,§1(4),and we have no 12.Fg Roof repairs insurance required.] t employees. (No workers' }3.❑ 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 their workers'comp,policy information. 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$1,50Q.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 uncle th pain a penalties of perjury that the information provided abov is true and correct Signature: Date: 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. ®ther Contact person: Phone#: i V Board of Building Regulations and Standards HOME IrROVEMENT CONT License or registration valid for individul use only Re Istr�tlon9 RACTOR 24310 before the expiration date. If found return to: 007 Board of Building Regulations and Standards One Ashburton place iWdual Rm 1301 ames Curley (ry _ I Boston,Ma.02108. rm es Curley 17 Fuller Rd. �\ � :nterville,MA 026322V �--• , rr-r�,i Administrator Not valid without sign, ure I , I i _ I I I I MTH pF�1q //o c STD,•3q�j ti 9� uCTUR ti � q� C..) STEREID q6 ETIG�N�„ r--.00 F� r oDi.Fi MICHELE C. TUDOR, P.E. Consultin Engineer p 123 Cottonwood Lone, Centerville, M0330chu3ett3 02632 f I rC Df?-cb Orown B : MCT ' 3 _. � ��I�. _ Y Dot z� o z D r a w i n loq Wl-sT AY. -HA �p� No Scale Rev.: 0 - - SKS - 1 File Nome:,.;.., Project No,:0Z_ i �. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map n ' Parcel 3 _y Permit# �v Health Division oLM - /)h j Date Issued -U¢Y Conservation Division Fee Tax Collector op r2e pS�r Dd SEPTIC SYSTE f,�UST 6E VU Treasurer 3 — ^�� INSTALLED IN COMPLIANCE Planning Dept. ENVIRON��ODEANO Date Definitive Plan Approved by Planning Board TOWN REGULATIONS Historic-OKH Preservation/Hyannis Project Street Address I` a 1A_2 BLS I Village n 5 a j� Owner pi 71 4— --t R Address Telephone Permit Request b d Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new 13G Valuation 77, D J d—" Zoning District Flood Plain Groundwater Overlay It Construction Type '`'�°"1'� y,. Lot Size d t `U Grandfatliered: E`l'Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family bY Two Family ❑ Multi-Family(#units) 4 ;+ Age of Existing Structure 7/6 0/0Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: Z+-ull ❑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 0161il ❑ Electric ❑Other / Central Air: ❑Yes b o Fireplaces: Existing New Existing wood/coal stove: ❑Yes Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use S�w�L L ��9v� I Proposed Use l/h z // /� .BUILDER INFORMATION ��0�' Sa-7 e'hi qi Name Cz/yV/C 1 /®Z'/v�/Z /r/ Telephone Number f� f' r Address /lJ A le aewt),SE License# :S / y/ /l Home Improvement Contractor# Worker's Compensation# �' j� �5� y L/ ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED 3 MAP/PARCEL NO. f _ ADDRESS 4 VILLAGE OWNER p DATE OF INSPECTION: FOUNDATION y A :. FRAME ' INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGHFINAL 4>- GAS: ROUGH 0. Y FINAL ' FINAL BUILDING, s 4 cl, DATE CLOSED 6-bT, '�'$ 0 1 ASSOCIATION PLAN NO. t . y ti� Msz�� - The Town of Barnstable - KASS "Regulatory.Services bprft6590. ►�0 Thomas F. Geiler, Director Building Division Peter F. DiMatteo'Building Commissioner 367.Main Street,Hyarittis MA 02601 508-862-4038 'Fax: 508-790-6230 HF —0. Permit no. -- o y. 6 4/ -1ev S _ Date d72G ' AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW . SUPPLEMENT TO _.PERMIT APPLICATION MGL C. 142A-requires that the"reconstruction.alterations,renovation.repairw modernization,conversion, improvement.removal,demolition,or construction of an addition.to any pre-existing owner-occupied, building containing at least one but not more than four dwelling units or to structures which are.adjacent to such residence or building be donety registered contractors,with certain exceptions,along with other' requirements. J '2i� 2 � Type of Work: / Estimated Cost_Z Address of Work: 144 S CJ Owner's Name: ' � � / Date of 4pplication: I hereby certify that: Registration is not required, for the following reason(s): ❑Work excluded by law []Job Under S1,000 , ClOuilding not owner-occupied C]Owner pulling own permit Notice is hereby given that: OWNERSPULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED. CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE- ACCESS TO THEARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL:c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. Date Contractor Name. Registration No. OR Date Owner's Name _= The Commonwealth of Massach usetts _ Department of Industrial Accidents 600 Washington Street Boston,Mass. .02111 s Workers' Compensation Insurance Affidavit name: location: city phone# ❑ I am a homeowner performing all work myself ❑ I am a sole vprietor and have no one workdi in any.capacit y ////%%//%%//%//%%%/%//%%%%%O%%//%/%%%%%//////%%%%%/%///O%%/////%////%%%%%/�///%%%/ ❑ I am an employer providing workers' compensation for my employees working on this job. ::::::::::.::::::::::::::::::::. ::::: .. . ... ......:' name-::;;:: : 2::;;:::;:;::;:�:::;:;:':: :::%:;::::::;%:::>:>;::::.';::::%>�::�:::-::%:: ::: ::=:::i;:::;::::::::::::::::::::::::::':2:::::ii:%':%;;%:::::::�:::.� :•::: -:._> -:::.::.,.::.�:::•.,:.:::._.�._.+.•:::::::.�:.�::::•::::::::..:.:.......:: rOIDDeIIY - •._ -: :: x..: ?,_....., :..{.{.::%'i`ii i::Q?:j:::;i{:i:{:;{:+:i;:i:'%) :::?�%i:v ii:t'4::}{;?:.:j%ti'i:! 4i:L:ii'i::Y:r:{,:if iii v;i{{:%chic.:iL':-%{.%i::t.:%::'{?ii::?:Y::j:::is:vi:i!%:!j�?i�i?::%i:....:.:.; ......:.:? %i:fi:i%ii:i%i:�ii:{%�:�i:++%iii:'vi:{:i::isii:%ii:i%'.isii%i:%iii:%i:%iii:%::ii:%ii::{•: hirv- :{i\iii:tvi%�i3:%i? j?iiii:tic[ti%ii:%:4ii:iiiiii:�:�::+�iii?i?:ii%i:-iiii?�ii>:{;{%:(•?i:{•i•:i?•?:•?:ii ::ii::{?{Yi::::ii:�:t::: �yiistira�n ❑ I am a sole proprietor; general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers' compensation polices: ....:..........:.....:........... ::::::v:::•i,......xvY.i•}1i-::::::::x...•'v:•v•••:L .:::{:.....:{%'iy:i�iL'% }v. :: .::??:vi?:'}:;i:; ;4 ::::-+.x:.:::.v::.v ::..{%:,..r?}:;n}:•.v,.v .....:::::.i:•.:,w: . r: '.. .....:::::::.v::::::•::::::.v:::::.:vLn•:.;..is .".::•is ::?.-::;{::}- ...... ....... hone.# ....:, i:{v: .............. . .... ..... r:;8i:$;•:jr:�r:}.iiiii%i:{:i%:�:%iLiiiii'}.v.. ..... ... .r{ {:;{•ir h;{L•?.:?'!. !J' r ::��.:::::.:: ....n.. . :::....v.r.........n.......r.....?:'4:{^:•??"i??ri:'i?f'�'!�:i:'. ...r::.:n.:v::w.....r...r.....v.. r .:...:..... ... .......v... :::•.::.w.v::.vr::: .�hsrirartce:cfl.:::::::•:: . .....:• ................;-:;:.............r....... .....r. .... .r.4...r....,...............................r.......... .....n.................n...... ij:?:%ciii is%iiiiiii:>%':{iii' !{-f8?'{;;•iii???:;-i'rj�:v:iT?iiii:vi%iiv±%�:ti:Yji:}j .::.:.::::.:::.:•:.:::v:::..:ri:v:L...............,................r. .-r:::::�•:::!•isi?iiii:�?:^i:{:::.::'vi::%'-.v..-.:,v?.v.v:::::::::::::ny:::.v.v.v::::n.{:.?':nv:.?:v%i:C{{;�i:i:;i:{.iii•.�.ii?:{::v5?:�:v:4?Yt:?:.??i:•?:i•ii�?ii:•:{:•:{•iii:•i ....{...........................r.::•.:.,...........:........... .. ......,.nv:n:v:�w:n,v::nv::n::::::::nxv:r:.nnv:::.nv.::vnv.v::::::::::.?.{v:::r:.::r.n:v::?.::::.:?:{:.?:{:{:•?}$:{.:?:•{{{:`:.Y:.v:::::::::•:•.v::: :.::.....:.....:::..::::..::....::..:::•-::n�:nr:•:::4::{.::................................................................................................................ ..:: .i`.•;.vjj;,{::::;:;i:'.%:{:}.i::y:':iii:i%::.:•.lii::ti!%i:+%?ii:%:%ii:i%i:%:'is i:',:;:%:;iti i:'::i:::%::j:':::: . .: •n:':i;-?•;v:i{;r!::??i?i:{?::4?}?}{•:�:•.'i????isv.,..'Fnn••;.;:•.....•::;•:.v'y:::�'i:•?:.::•i?•-{{rv:4?iii:•i:•'r.;^i:•:�i;•�v:^:v'1^:•? VLl�: �??:L:L6:?{•i:{• :?L-r:8;{f•?•.:•::;:i'j:-L.:`.jji:i%:4i::-isi{:Y::;}:'j�;i:;:^,i:;:j::}S.'-r?:?r:i; 1:!i.is?• Insurance.ro.:.::.:.r...:..:.:::::.:..::::-::::..:::::.::::::::::..::..:{.:.;;::::.:>:;.::•.L:.:::.?:....:.r Failure to secure coverage as regWred mnder•Section 25A of MOL 152 can lead to the tmpositlon of criminal penalties of a fine to 51;500.00 and/or one years,imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I mnderstmil that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification I do hereby certify under the pains and p epallies ojperj cleat th nformadon provided above is truce and co ed Date 3 Signature y / . A Z,___ Print name /" `� ✓ Phone# oincial use only do not wrtte in this area to be completed by city or town official city or town: permitilicense# (]Building Department ❑Licensing Board ❑checkif immediate response is regmred ❑Selectmen's Office OHealth Department contact person: phone#; ❑Other ----------------------- Devised 9195 PJA) Information and Instructions iassachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their nplovees. As quoted from the "law'; an employee is defined as every person in the service of another under any contract Shire, express or implied, oral or written. ,n employer is defined as an individual, partnership, association, corporation or other legal entity, or any two or more of ie foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or ustee of an individual,partnership, association or other legal entity,employing.employees. However the owner of a welling house having not more than three apartments and who resides therein; or the occupant of the dwelling house of nother who employs persons to do maintenance, construction or repair work on such dwelling house or on the.grounds or uilding appurtenant thereto shall not because of such employment be deemed to bean employer. 4GL chapter 152 section 25 also states that every state or local licensing agency shall withhold the-issuance or renewal f a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has rot produced acceptable evidence of compliance with the insurance coverage required. Additionally,.neither the ommonwealth nor.any of its political subdivisions shall enter into any contract for the performance of public work until cceptable.evidence of compliance with the insurance requirements of this chapter have been presented to the contracting uthority. applicants 'lease fill in the workers' compensation affidavit completely,by checking the box that applies:to your situation and upplying.companx:names, address and phone numbers along-with a.certificate of insurance'as all affidavits may be ubmitted to the Department of Industrial Accidents for confirmation of insurance coverage-. Also be sure to sign and. late the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is ieing requested, not the Department of Industrial Accidents. Should you have any questions regarding the'law'or if you ire required to obtain a workers' compensation policy,.please call the Department at the number listed below. :ity or.Towns ?lease be-sure that the affidavit is*complete and printed legibly. The Department.has provided a space at the bottom of the Lffidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please )e.sure to-fill in the per3iit/liceQse number which will be used as a reference number. The'affidavits-may be returned t�+ . he Department by mail or FAX iialess-othei`ariangements the Office of Investigations would like to thank you in advance for you cooperation and should you have any questions. ?lease do not hesitate to give us a call. the Department's address,telephone axed fax number: ' The Commonwealth .Of Massachusetts, Department of Industrial Accidents Me of Investlgatlons 600 Washington Street Boston,Ma. 02111. fax#: (617) 727-7749 phone#i (617) 727-4900 ext. 406, 409..or.. 375. RESIDENTIAL BUILDING PERNIIT FEES APPLICATION FEE New Buildings,Additions $50.00 - Alterations/Renovations $25.00 Building Permit Amendment $25.00 . FEE VALUE WORKSHEET NEW LIVING SPACE // square feet x$96/sq.foot= 3 �� x.0031= `7 ' plus from below(if applicable) ALTERATIONS/RENOVATIONS OF EMSTING SPACE square feet x$64/sq.foot= x.0031= plus from below(if applicable) ACCESSORY STRUCTURE>120 sq. >120 sf-500 sf S 35.00 >500 sf-750 sf 50.00 >150 sf- 1000 sf 75.00 - >1000 sf-1500 sf 100.00 >1500 sf-Same as new building permit: square feet x$96/sq.foot= x.0031= STAND ALONE PERMITS Open Porch x$30.00= (number) Deck x$30.00= (number) Fireplace/Chimney x$25.00= - (number) Inground Swimming Pool $60.00 I Above Ground Swimming Pool $25.00 Relocation/Moying $150.00 (plus above-if applicable) l Permit Fee projcost l Table J1=b(condoned) . preeerip"ve Package for One and Two-Fa=*RaajdaarW BW MhW Heated with FoaaiJ Faeb MAXIMUM NIMMI I 1. Glazing Glazing Ceiling Wall Flow Baataaeest. Slab cicMuy,. Area'(•/.) U..�Juc: P.value'. I;value' R valad Wall Padm.Qe R.valnoi &vnJ� 5"1 to 6500 Heads;Decree Dam Q 12:'. . 0.40 3E 13 19. . 10 6 Normal R 12% 1 0.52 30 19 19 10. 6 Nord 3 120,11 0.50 3E 13 19 10- 6 as AFUE T 15% 0.36. 31 13 . 25 WA wt Normal U 15% 0.46 33. 19 19 10• 6. Normal V 1SY. 0.44 33 13 25 wA WA. is AFUE W is% U2 30 19 19 • 10 6 is AFUE X IE% 0.32 3f. 13 2s wA N/A Normal Y 18%. 0.12 3f 19 23 WA wA Normal Z If;%. 0.42 33 13 19 10 6 :j=90AFETE AA 18% OJo 30 19 19 10 6 90 A1ZJE 1. ADDRESS OFPROPERTY: 2. SQUARE FOOTAGE'OF ALL EXTERIOR WALLS: 3. SQUARE FOOTAGE OF ALL GLAZING: 4. %GLAZING AREA(#3 DIVIDED BY#2): S. SELECT PACKAGE(Q—AA-see chart above): NOTE: OTHER MORE INVOLVED METHODS-OF DETE WNING ENERGY REQUIREMENTS ARE AVAILABLE. ASK US FOR THIS INFORMATION. 7�✓ eoZt/ BUILDING INSPECTOR APPROVAL: YES: NO: q-forms-f9 B0303 a Footnotes to Table J5.2.1 b: Glazing area is the ratio of the area of the glazing assemblies (including sliding-glass doors, skylights, and basement windows if located in walls that enclose conditioned space,but excluding opaque doors)to the gross wall area. expressed as a percentage. Up to 1%0 of•the-total glazing area maybe excluded from the U•value requirement. For example.3 ft'of decorative glass may.be excluded from a building design with 300 fl of glazing area. After January 1, 1999, glazing U-values must be tested and documented by the manufacturer in accordance with the National Fenestration Rating_Council (NFRC) test procedure, or taken-from Table 11.5.3a: U-values are for whole units:center-of-glass U•values cannot be used. ' The ceiling R-values do'not assume a raised or oversized truss tonstruetion. If the insulation achieves the full exterior walls without compression, R 30 insulation may be substituted for R-- insulation thickness over the insulation and R-38 insulation may be substituted for R-49 insulation. Ceiling R-values represent the sum of cavity insulation.plus.insulating sheathing (if used). For ventilated ceilings, insulating sheathing must be placed between the conditioned•space and the ventilated portion of the roof. 'Wall R-values represent the sum of-the wall cavity insulation phis insulating sheathing (if used):Do not include exterior siding, structural sheathing,and interior drywall For example;an R.19 requirement could be met EITHER by R-19 cavity insulation OR R-13 cavity insulation plus R-6 insulating sheathing. Wall requirements apply to wood-frame or mass(concrete,masonry,log)wall constructions,but do not apply to metal-frame construction. 'The flooi requirements apply to'floors over unconditioned spaces(such as unconditioned crawispaces;basements, or garages).FIoors over outside air must meet the ceiling requirements. '7r.e`entire opaque,portion of any individual basement wall with an average depth less than 50%below grade must mC.: the-same, R-value.requirement as above-grade walls. Windows and sliding glass doors of conditioned br..,ements must be included with.the other glazing. Basement:doors must meet the door U-value requirement d-scribed in Note.b. 'The R-value.requirements am:for unheated slabs.Add an additional R-2 for heated slabs. ' If the building utilizes electric resistance heating use compliance approach 3;4, or S. If you plan to install more than one piece of heating equipment or more than one piece of cooling equipment, the equipment with the lowest efficiency must meet or exceed the efficiency required by the selected package. . 'For Heating Degree Day requirements of the closest city or town see Table J5.2.1a NOTES: a)GIazing areas and U-values are-maximum acceptable levels.Insulation R-values are minimum acceptable levels. R-value requirements are for insulation only and do not include structural components. b) Opaque doors in the building envelope must have a U-value no greater than 035. Door U-values must be tested and documented by the manufacturer.in accordance with.the NFRC test procedure-or-taken from the door U-value in Table 11.5.3b. If a door contains glass and an aggregate U-value rating for that door is not available, include the glass area of the door with your windows and use the opaque door.U-value to determine compliance of the door. One door may be excluded from this requirement(i.e.,may have a U-value greater than 035). c) If a ceiling,wall,floor,basement wall,slab-edge,or crawl space wall component includes two or.more areas with different insulation levels,the component complies if the area-weighted average R-value is greater than or equal to the.R-value requirement for that component: Glazing or door components.comply if the rea•weighted average U- value of all windows or doors is less than or equal to the U-value requirement(035 for doors). 43 P Y' ti;:-, _' _: i 3 (T c t ' .. z T.MiLrW-]DDIVYf VV - n q : 4 t f k R �� {ty)x'('I TTn�.� tfyQ (..,N.}-�_q dl tS."Sif l a'�9tJ4 Et is�'1 r .3�.�. '�. 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I C` ,-�t: A;)' f., D l"r'CD+ t'Ht' (!.t? \)._:-(S. C..,:1•` OR RHRISE:N"t'ATI)ES 4 TlCltr ti.4 PI}Rtiir\rA 1';T.i NIP B r r 1 I . Or 1 BOAR©OF QW[LID � d ING RE iLicense:Q,®NSTR-UCTIO, h Number`GS 038866 r Birth�ate04/30/9949 Ex-IN s'�04�30%Q02 Restricted To'-``0, r FRANK K HEIDENRtCFi.. i 95 MILI>6E RD O6IVILLE, `MA 02655 A°dffimist I i 1 i P i Tv �STS £ xt s 7-1 "JG- v�J i.f i S I 77-H � s SEC rl �vv k\ �i MAP 11 'r MAP 116 3 / 3 -2 109 MAP 116 3 33 # -121 AP 11 b f:\dgn\conservation.dgn 03/05/02 10:43:18 AM i T1iE COMMONVVFALTR OF MASSACdards 3 Transaction No. Board of Building Regulations and Stanch One Ashburton Place•Room 1301 (� Boston,MLwachmetta 02103 R anon No. Application for Registratlon as a 13ieaire Date' Some Improvement Contractor or Subcontractor Fxpbation Date MGL Chapter 141A► CMR 780.6 ova OFtCZ Use ONLY Date 1. Name ; ual or b=wm spp"t tar me t (Got both) 5� Gc�� Print the name of the insimd S .� U Z Mailing Address Q C� �' Alta Code A Telephone Nutaber a, street Add:as(ifFIEff&W CUY N,, (P.O.Ban Dot seet�ssbu). 0 public Carpostiaa S. Apples rJP� �=a Q ddw the Q .n•��yw•MGL r110.as S (See►nswtuons oa back ttptd+tii O? 3�'CkY S�./G e. (lilac ) T. Number of F=PI�--�--- .6. Sooal Socurity or Federal ID Nttttsba o?� 3 S�/tom for Home Imp�tsst CaDte+� 'f -------- IV 2/C/� � � / Social 5ecsuity No IL . ladMdttal eep�le lid Fast eZ 2 9. Try of Individtal rapo antic for Hattie Imptow nied Connuo idated note l .aq, awn Ttoeatwe'err�yoasT mdMdml hold m7 alter ec m eettoo Yts No l0. D tahlethe Use additional Papa Lars at Name of Lice»se Nokia Type license or�1p1° Intiod I3y! buaaioa tttimhe Dull 'i 0 CoA)S • �aotpoaaiion blow.Use dttt step ttad major Owner(10%or pate of owatsship)of tm aPp pattomivP l List so partners.trasees.offlee=a6 for tulditlonal ID aids for kq pasons. additional papa if DAY. e ins"n, I eo had) Cheer htse II aim+wish to teoeive tm ' list Fleet. Middle ittitW 'Ellie illApPticattt Business. . 96 owner �� 52) 5 ` 0o tut:beet) 12 .Is the sppliant daimitii cmmpsiaa ftam the t fee? (see the license or ttstrititm ,• - No I f yes.include a copy of a Covent ComtrtiClot,SUPWASW h�or moeorvehi��+hap _ Rind fee t S MUST 'Re0= 'G Fund•. AI1.APPLICANTS 13. Re i10II tea tmdosed:S aontets-otae madtd' o'er Fa"•otie marked uboutt Include tao Wpae+t<eestiaccl eheAs err>s� ff FROM T M REGNMATTON F13+See oti�for amount of fees INCLUDE A GUARANTY FUND FEE E'VF3t to•cammonweam of Maaaachmesw Make ad ossdW�or moocy tudas payable Iiws Qtapter 62C 49A;I en"ttadee�psaaltles of UW"erjury that 1. Pnrsoaat to MImachmetts Geond revaus WW paid all state tan regttlred under low. to ael'best loaowledtie belleL bane filed all T►tle held with appliant Signstu of appliant or appG a repseeatatrtre lican►'s registration A false anwer to an7 quntloa is this Application eonsumus t�°b for saspeasioo or tnooUon of the aPP �0*SME TI);sy own of 13arnsEauit: Expires 6 r nrl s%rcro ss a as e 00 Fee _ Regulatory Services �t �0m�r Thomas F.Geller,Director �. 9�A.i°19' ►�' � Building Division •��� Peter F.Diliatteo, Building Commissioner r 367 Plain Strew. Hyannis,MA 02601w NO �� ���+�, Office: �o$-sb=-o:s T�vVN 1200, oF Fax: :08-790-6:=0 EX-PRESS PERMIT iPPLICaTION - RESIDENTIA lv L iSTgeC � Not.Valid without Rid X Pms Itnp F Map.,parcei N'uartber w af I LP PC, . 3 Oq Proper I-O . 00 / Value of Work [�I Residential owner's:Fame&:address lob c,�. 3 P�4 Os�er�i� _Telephone Number Contractor's Name � �3 � O Home Improvement Contractor License.. (if appitcable) r Construction Supervisor's License=(if applicable) ' GWorkman's Compensation Insurance k one: - -- T am a sole proprietor I am the Homeowner C 1 have Worker's Cotnnensation Insurance Insurance Company game Worim=,s Comp.Policy Permit Request(check box) Q Re-roof(sU#Ping old shingles) �s 1 [i Re-roof(not stripping. Going over existing layers of roof) Q Re-side Q Replacement Windows. U-Value ( 44) other(spec&) required: of this permit does not exempt conrpiiance with ocher town deparm=t regulations.�.e.Historic.Conservation.e: Where teq � , Signature Q:Fonrs:v1omtrc:r-'v41?060l •;/fie TDa"vnranu�°�' °�� . B g oard of Buildin Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registrattionc. 124310 ..Expiration:' -0610112003� i. lug, c� •:,__-�7yPe:�lndivid ' James Curley James Curley Ivan In PO Box 231198 Sy Administrator Osterville,MA 02655 '