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Home My WebLink About0021 BANCROFT CIRCLE 21 BANCROFT CIRCLE 12543-- . - No. 53LOR ------------ Town of Barnstable Building a�'sewet,� ' Post This Card So That it is Visible From the Street-Approved Plans Must be Retained on Job and this Card Must be Kept M Posted Until Final Inspection Has Been Made. Permit ---------- ` I Where a Certificate of Occupancy is Required,such Building shall Not be Occupied until a Final Inspection has been made. ------ Permit No. B-19-1633 Applicant Name: ROBERT BANCROFT Approvals Date Issued: 05/28/2019 Current Use: Structure Permit Type: Building-Addition/Alteration-Residential Expiration Date: 11/28/2019 Foundation: Location: 21 BANCROFT CIRCLE,WEST BARNSTABLE Map/Lot: 215-013 Zoning District: RF Sheathing: Owner on Record: HILL, PAULA& PAI,JITENDRA Contractor Name: Framing: 1 Address: 23 WEST 104TH ST APT 2B Contractor License: 2 NEW YORK, NY 10025 Est. Project Cost: $4,500.00 Chimney: Description: INVERTED DORMER RUBBER ROOFING REPLACEMENT REPLACE Permit Fee: $85.00 RUBBER ROOFING UNDER 12'X10' DECK ON INVERTED DORMER TO Fee Paid: $85.00 Insulation: REPIR CARPENTER ANT DAMAGE AND HOT WATER LEAKS.THIS Date: 5/28/2019 Final: DORMER IS ABOVE KITCHEN. HOME HAS A WOODEN CEILING WHICH ANTS HAVE SEVERLY DAMGED REQUIRING REMOVAL OF DECKING ROOFING RUBBER MEMBRANE AND SOME SIDING &TRIM Plumbing/Gas ALL TO BE REPLACED BY THE SAME Rough Plumbing: Building Official Project Review Req: Call for framing and Insulation Inspection Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. Rough Gas: All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. Final Gas: 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 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. Service: Minimum of Five Call Inspections Required for All Construction Work: 1.Foundation or Footing Rough: 2.Sheathing Inspection 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 Low Voltage Rough: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Health Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Workshall 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 �O SSE Os 3J Application Number.B-t ..^... ............... BARN6I'ASLE, �p..�' BUf LDIND D EPT Permit Fee.......................................Other Fee........................ Total Fee Paid....................................i.. ... MAY'1 g 2019 �� •• ��°� TOWN OF B � Permit Approval by.. .. ....................On.�...� ...�..1 NSTABLE BUILDING PERMIT Map.. ...........Parcel...... . APPLICATION Section I — Owner's Information and Project Location tProject Address ; c Village . 1'1 A Owners Name ` �jj Owners Legal Address-p ' %3� -� 1, (�G City.3 ( y 90)}' � State Zip L-)(06 d Owners Cell# - EZ� E-mail 0 G Section 2 —Use of Structure Use Group ❑ Commercial Structure over 35,000 cubic feet ❑l Commercial Structure under 35,000 cubic feet L�J Single/Two Family-Dwelling Section,3---- -Type of Permit ❑ New Construction ❑ Move/Relocate ❑ Accessory Structure ❑ Change of use ❑ Demo/(entire structure) ❑ Finish Basement ❑ Family/Amnesty ❑ Fire Alarm Rebuild ❑ Deck Apartment ❑ Sprinkler System ❑ Addition ❑ Retaining wall ❑ . Solar Renovation ❑ Pool ❑ Insulation Oth r pec, A r r n � to 4 (Section 4 - Work Description / Aa-lla r h d e /. . / 0 V, `. I- P a .. �,,, � a. g Application Number.................................................... Section 5—Detail a Cost of Proposed Construction �44a, Square Footage of Project g _ • 6 6 1�'.r � Dig Safe Number Age of Structure' � #Of Bedrooms Existing Total#Of Bedrooms (proposed) 110 MPH,Wind Zone Compliance Method; ❑ MA Checklist ❑ WFCM Checklist ❑ Design Section 6—Project Specifics ❑ Wig ❑ Oil Tank Storage ❑ Smoke Detectors ❑ Plumbing ❑ Gas ❑ Fire Suppression ❑ Heating System ❑ Masonry Chimney ❑Add/relocate bedroom Water Supply ❑ 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 El 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 T act n„riotP+ 11/1,;nnl Q Application Number........................................... Section 9= Construction Supervisor Name Telephone Number Address City State Zip License Number License Type Expiration Date Contractors Email Cell # 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.Attach a copy of your license. Signature Date Section 10—Home Improvement Contractor I Name Telephone Number Address City State Zip Registration Number Expiration Date 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 CMR and the Town of Barnstable.Attach a copy of your H.I.C... Signature Date Section 11 —Home Owners License Exemption Home Owners Name:T6 6n�72,9,h C h 4 Telephone Number 7 f Cell or Work Number 'Z2z.. l I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts S to Building Code. I understand the construction inspection procedures,specific inspections and documentatio e d by 80 CMR and the Town of Barnstable. (S� Date PLICANT SIGNATURE .1l Date / ' / riot Dame W Telephone Number 3 Y13 E-mail permit to: / 16 � Cj6 11, Section 12—Department Sign-Offs Health Department Zoning Board(if required) D Historic District Site Plan Review(if required) Fire Department Conservation Qj For commercial work,please take your plans directly to the fire department for approval, Section 13 — Owner's Authorization I, , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of job) Signature of Owner date Print Name I i e. STD. 3 Al :r I J I I �N �i o p O ! I ct I I 1p mA 1 The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Invesfigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit:Bwlders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organiz onftdividual)• - Address: 4 r Ra Y' R 6 City/State/Zip: - r . Phone#: 2 2 Are you an employer?Check the appropriate box: Type of project(required): 4. I am a general contractor and I p J ( � .�� 1.❑ I am a employer with g 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling ship and have no employees These sub-contractors have g. Demolition working for mein an act employees and have workers' . rking Y capacity. t 9. ❑Building addition [No workers'comp.insurance comp.insurance. required-] 5. We are a corporation and its 10.0 Electrical repairs or additions 3.[� a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself[No workers'comp. right of exemption per MGL 12.[UAKgof repairs insurance required.]t c. 152,§1(4),and we have no 13. drer r / G -� employees.[No workers comp.insurance required.] ", *Any applicant that checks box#1 most also fill out the section below showing their workers'compensation policy information. G O t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such t(Contraetors that check this box must attached an additional sheet showing the name of the sub-cont actors 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 ray 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 hereb certify n the pants and penalties of perjury that the information provided ave is true and correct cS DZ2 // ate: -Phone#:' Q)Icial use only. Do not write in this area,to be completed by city or town off kial City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.EIectrical 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 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 numbers)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 cant'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 numiber.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 pennittlicense 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 firhure 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 Aeddents ffitce of Investigaflow 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;mass.gov1dia Parcels FY2a18 , ... s: Address Street Numbers 216-068 041=118 Town Boundary # 29 [� Approx.Building ED Buildings ® Decks/Patios 0 r7, Above Ground swimming Pools 216-002-001 ' QQ In Ground Swimming Pools #39 216-001 Paved Walkways #830 -=== Unpaved Walkways ' Paths ® Stairways I Paved Roads Unpaved Roads- - Paved Driveways •l.'..'. "� ' .., -_ Unpaved Driveways ;':•, .:'!':,'.:' ;'_:i'...::::.';.:._'- ;,';l ,- H- Painted Lines OPaved Parking Lots Unpaved Parking Lots 1: ••;� \, - B ® Bridges Railroad :• I \;< ROFT Fences ''i' _:...- Q; --a Guardrails i 1 —G— Retaining Walls Stone Walls /! \ - —• Other Walls Fledges QOSports Areas Ar eas reas i ...C ` t -01� •\ 5 3 Docks/Piers 2.1# ,2 J1 \ ® Boardwalks tp Y Q: Jetties ^' --- Streams O Y \ Drainage Ditches N `� r Marsh Areas \� k ) Water Bodies Spot Elevations(NAVD88) Topo to ft Contours(NAVD88) -- �.. WootT�lP9tYe@sCgfTourNAV-D88) . yn met frees 7e Cotchbasins Monuments Lamp Posts Satellite Dish Manholes - 215-012 QQ Fuel Tanks #800 G) Utility Poles ®®water Tanks Signs Flagpoles 21 76. i Town of Barnstable Data SOUI'CC Human-made features, [)iSC(rtillter This map is for planning purposes only. It is 1 inch=3ofeet hydrography,topography,and vegetation were Parcel lines on this map are only graphic not adequate for legal boundary determination _. Feet Conservation Division interpreted from 2014&2008 aerial photos representations of Assessor's tax parcels.They or regulatory interpretation.This map does no O 5 10 20 30 40 w- litim//www.town.barnstable.ma.US and may have been updated from more current are not true property boundaries and do not represent an on-the-ground survey. .� ,. Town of Barnstable Building Post This Card So That it is Visible From the Street-Approved Plans Must be Retained on Job and this Card Must be Kept M Posted Until Final Inspection Has Been Made. Pit `Jt jjj �Ma+° Where a Certificate of Occupancy is Required,such Building shall Not be Occupied until a Final Inspection has been made. Permit Permit No. B-18-3329 Applicant Name: BANCROFT, ROBERT Approvals Date Issued: 10/31/2018 Current Use: Structure Permit Type: Building-Shed-Residential-200 sf and under Expiration Date: 04/30/2019 Foundation: Location: 21 BANCROFT CIRCLE,WEST BARNSTABLE Map/Lot: 215-013 Zoning District: RF Sheathing: Owner on Record: BANCROFT,ROBERT Contractor Name: Framing: 1 Address: 21 BANCROFT CIRCLE Contractor License: 2 WEST BARNSTABLE, MA 02668 Est. Project Cost: $0.00 Chimney: 35.00 Description: install a 10x16 shed Permit Fee: $ Insulation: Fee Paid: $35.00 Project Review Req: Date: 10/31/2018 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. Rough Gas: All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. Final Gas: 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 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. Service: Minimum of Five Call Inspections Required for All Construction Work: 1.Foundation or Footing Rough: 2.Sheathing Inspection 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 S.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: " erso ontracting 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 Town of Barnstable BUILD Regulatory Services Richard V.Scali,Interim Director OCT BAMSfABM _ „„S, Building Division 21 201 p 039. �' Tom Perry,Building Co issioner TOWN�� 200 Main Street, Hyannis,MA 02601 8qWS' www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 PERMIT# FEE: $ � SHED REGISTRATION RESIDENTIAL ONLY 200 square feet or less - 0 ' C,� I r- e, Location of s ed(address) Village Y` L �Cr'd�� Property owner's name Telephone number 0 ��— J� Size of Shed Map/Parcel# 1 4Sik6aturFel : Date Hyannis Main Street Waterfront Historic District?Old King's Highway Historic District Commission jurisdiction? �,e 'If over 120 square feet,you must file with Old King's Highway Conservation Commission(signature is required) Sign off hours for Conservation 8:00-9:30&3:304:30 PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FORM MUST BE ACCOMPANIED BY A PLOT PLAN Q-forms-shedreg REV:110413 �s � Parcels FY2018 Address Street Numbers 216-068 IM�]ura Town Boundary # 29 Approx.Building Buildings ® Decks/Patios _ J I g 16-002-00] Above Ground Swimming Pools t � �� &� IF-1In Ground Swimming Pools UT, � #O � 216-001 Paved Walkways CO r _ #$30 Unpaved Walkways tt�l i ; Paths � Q 6 Stairways �� •.. 'V \\ - _ Paved Roads ZZ7:1 Unpaved Roads m- \\ 0 Paved Driveways Unpaved Driveways , I-�- Painted Lines `i ��•. ! �..- 1 Paved Parking Lots Unpaved Parking Lots Bridges -F— Railroad Fences , .7 • Guardrails 6 <> Retaining Walls • Stone Walls- V Other Walls :. "<T Hedges Sports Areas Golf Areas d r ' 2.1�5-01�3 � •.� v Docks/Piers Boardwalks •, ',m Jetties \ Streams 1� Drainage Ditches r✓ Marsh Areas O Water Bodies Spot Elevations(NAVD88) _J Topo to It Contours(NAVD88) WoocfAPAPefIs� ou (NAV�88) ', ':;� / ) frect Trees Catchbasins Monuments Lamp Posts Satellite Dish Manholes 215-012 O■Fuel Tanks #800 ............... Utility Poles ®®Water Tanks Signs Flagpoles 215 012 • Data Source liuman-made features, Disclaimer, town of Barnstable This map is for planning purposes on]y. It' ]tree/i=,30fect N hydrography,topography,and vegetation were Parcel lines on this map are only graphic not adequate for legal boundary determination Feet ►reservation Division interpreted from zolq&zoo8 aerial photos representations of Assessor's tax parcels.They or regulatory intcrprcrirtion.T1ris map does no 0 5 10 20 30 40 w E a httn://www.town.barrrstable.ma.us area may have been updated from more current are not true property boundaries and do not represent an on-the-ground survey. J BENNETT ENVIRONMENTAL ASSOCIATES, INC. LICENSED SITE PROFESSIONALS,ENVIRONMENTAL SCIENTISTS,GEOLOGISTS,ENGINEERS 1573 Main Street,'P.O.Box 1743 (508)896-1706 Brewster,MA 02631 fax(508)896-5109 LETTER OF TRANSMITTAL TO: DATE: JOB NUMBER: MassDEP SERO 12/28/16 Bureau of Resource Protection-Waterways Regulation [BEA16-10892 Program 20 Riverside Drive REGARDING: Lakeville,MA 02647 Chapter 91 Simplified Waterways License Application 21 Bancroft Circle Barnstable,MA SHIPPING METHOD: Regular Mail ❑ Pick Up ❑ Priority Mail ❑ Hand Deliver ❑ Express Mail ❑ Other ❑ Certified Mail ❑ Green Card/RR ❑X COPIES DATE DESCRIPTION 1 Chapter 91 Waterways License Application with Simplified License Plan Copy of Order of Conditions MassDEP File#003-5422 Copy of Transmittal Form for Permit Application and Payment and fee(original to Lockbox) For review and comment: ❑ For approval: ❑x As requested: ❑ For your use: ❑ REMARKS: cc: Darcy Karle,Barnstable Conservation Administrator* Richard Scali,Barnstable Zoning Agent*� Elizabeth Jenkins,Barnstable Regulatory/Design Review Planner Barnstable Town Council-Attn:Cynthia Lovell,Administrator* Katherine.Manni,Abutter* Varma Sundelin,Abutter* Bob&Lisa Bancroft,Property Owners MassDEP Lockbox** *Application and Plan only **Transmittal Form and Fee only FROM: Kara Risk,Project Manager If enclosures are not as noted,kindly notify us at once The Commonweafth Of Massachusetts iy4 No MassD1911 ONLY SITAPURED LICENSE BRP WW06 Applicant must fill in pages 1 and 2 of this license. Robert& Lisa Bancroft of the Town/City of: Barnstable in: Barnstable Applicant's name Town/City County County and Commonwealth aforesaid, has applied to the Department of Environmental Protection for a Simplified License to: Please check: ❑ maintain an existing (pre-1984): ® construct a proposed or maintain an existing (post-1984): Please check all that apply below: Please check all that apply below. ❑ pier/dock ® pier/dock ❑ boat ramp ® ramp ❑ ramp ®float(s) ❑ float(s) ❑ pile(s) ❑ pile(s) ❑ boat lift ❑ boat lift ❑ pile-supported boat house ❑ boathouse ❑ other ❑ retaining wall/seawall ❑ bulkhead ❑ rip rap/stone revetment ❑ groin(s) ❑ Nonwater-dependent(NWD) residence ❑ other and has submitted plans of the same; and whereas due notice of said application has been given, as required by law, to the[Please check one:] ❑ Board of Selectmen ® Mayor and City Council, of the Town/City of: Barnstable Town/City NOW, said Department, having heard all parties desiring to be heard, and having fully considered said application, hereby, subject to the approval of the Governor, authorizes and licenses said Licensee, subject to the provisions of the ninety-first chapter of the General Laws, and of all laws which are or may be in force applicable thereto, to: Please check all that apply: Please check all that apply: ® maintain existing structure(s)for: ❑ construct and maintain structure(s)for: ® non commercial docking/access to navigable water ❑ non commercial docking/access to navigable water ❑ shoreline stabilization ❑ other ® residential, NWD building ❑other in and over the waters of: waterway Garrets Pond in the Town/City of: Barnstable Town/City and in accordance with the locations shown and details indicated on the accompanying License Sketch Plan No.5Ia`1_D USE ; (total number of Sheet(s):FOR D P`15 ig,OR 3,, ) License#b Page 2 The total area of the combined structures,measured below mean/ordinary high water shall be no greater than a total of 600 square feet for proposed water-dependent structures, or for structures built or substantially altered after January 1, 1984 without any fill. For structures or fill constructed prior to January 1, 1984 and not substantially altered since that date:any structures and fill,either water-dependent or nonwater-dependent, total no more than 600 square feet. In both instances structure is not a 'marina(i.e.does not serve ten or more vessels). Dimensions of all structures are shown on the accompanying plan(s). "I hereby make application for a-License to authorize the activities I have described herein. Upon my signature, I agree to allow the duly authorized representative of the Massachusetts Department of Environmental Protection to enter upon-the premises ofthe project site at reasonable-times for the purpose of in.specti.on..I hereby certify that the information submitted in this document is true and accurate to the best of my knowledge. And, upon my signature, that I have read the License and conditions and agree to the terms and conditions set forth herein." BOX A: Robert& Lisa Bancroft Print Name 21 Bancroft Circle Mailing Address Barnstable Cityrrown(not village) MA 02668 Barnstable State Zip Code County 508-996-5611 (area code)telephone -mail Notification: i Your signature to the right certifies you have notified thd entities as checked off in Ile 71 .. boxes below. SiTnatqWpp1iKK_ Date Notification of application has been provided to:(please Z Local evffferv6tion commission [I Board of Selectman Mayor and City Council check) Zoning Authority Planning Board and has been sent by certified mail to:(please check) ED Abutters ❑Interested-Parties ❑Landowner(if not applicant) BOX B: If site address is different from mailing address: Site Address of the structures Gityrrown State Zip Code County BOX C: If the applicant is different than the owner: Owner Engineer/Agent NOTE, This License is not valid until such time as it has been numbered and signed by the appropriate State officials(see page 5)and recorded at the Registry of Deeds. - ------------ License#IDERUSKONtY. Page 3 USE: The structures authorized herein shall be for private non-commercial use of the licensee. The structures shall not be used for commercial purposes, leased, rented or otherwise let for compensation. Any change in use shall require an amendment to this license by the Department. The structures authorized herein shall be limited to the following uses: noncommercial docking and boating access to navigable waters. TERM: This License will expire fifteen (15) years from the date of License issuance. By written request of the Licensee for an amendment, the Department may grant a renewal for the term of years not to exceed that authorized in the original license. WATERWAYS CONDITIONS: 1. ACCESS: In accordance with any License condition, easement, or other public right of lateral passage that exists in the area of the subject property lying between the high and low water marks" or"below the ordinary high water mark", the Licensee shall allow the public in the exercise of such rights to pass freely over, under or around all structures within such (intertidal) area. Accordingly, the Licensee shall place and maintain, in good repair, a public access sign on the easterly/westerly or northerly/southerly sides of the pier/dock, authorized herein or at each property line, adjacent to the high water shoreline. Said signs shall comply with the Department's signage guidelines (see instructions) and shall be posted immediately upon license issuance or completion of construction. Nothing in this condition shall be construed as preventing the Licensee from excluding the public from portions of said structure(s) or property not intended for lateral passage. In partial compensation for the private use of structures and/or fill on tidelands and/or private tidelands and/or Great Ponds which interferes with the rights of the public to use such lands, the Licensee shall allow the public to pass on foot, for any purpose and from dawn to dusk, within the area of the subject property lying seaward of the high water mark or, for Great Ponds within the public access way delineated on the License plan/or within 5 feet of the ordinary high water shoreline. This condition shall not be construed to prevent the Licensee from taking reasonable measures to discourage unlawful activity by users of the area intended for public passage, including but not limited to trespassing on adjacent private areas and deposit of refuse of any kind or nature in the water or on the shore. Further, the exercise by the public of free on-foot passage in accordance with this condition shall be considered a permitted use to which the limited liability provisions of M.G.L. c.21, s17c shall apply. 2. This License authorizes structure(s)and/or fill on: i EOR�MassDEP'U$EONLY ___ - -- ---- -- In accordance with the public easement that exists by law on private tidelands, the Licensee shall allow the public to use and to pass freely upon ❑ Private Tidelands the area of the subject property lying between the high and low water 1 marks, for the purposes of fishing, fowling, navigation, strolling and the i natural derivatives thereof. i The Licensee shall not restrict the public's right to use and to pass freely, ❑ Commonwealth Tidelands ': for any lawful purpose, upon lands lying seaward of the low water mark. The Commonwealth holds said lands in trust for the benefit of the public. ' ❑ Great Pond The Licensee shall not restrict the public's right to use and to pass freely upon lands lying seaward of the high water mark for any lawful purpose. ❑ Navigable River or Stream The Licensee shall not restrict the public's right to use and to pass freely, for any lawful purpose, in the waterways 3. Unless otherwise expressly provided by this license, the Licensee shall not limit the hours of availability of any areas of the subject property designated for public passage, nor place any gates, fences, or other structures on such areas in a manner that would impede or discourage the free flow of pedestrian movement thereon. No restriction on the exercise of these public rights shall be imposed unless otherwise expressly provided in this license. r License#DEP IT$EONt;X Page 4 4.Any change in use or any substantial structural alteration of any structure or fill authorized herein shall require the issuance by the Department of a new Waterways License in accordance with the provisions and procedures established in Chapter 91 of the Massachusetts General Laws. Any unauthorized substantial change in use or unauthorized substantial structural alteration of any structure or fill authorized herein shall render this Waterways License void. 5. This Waterways License shall be revocable by the Department for noncompliance with the terms and conditions set forth herein. This License may be revoked after the Department has given written notice of the alleged noncompliance to the Licensee and those persons who have filed a written request for such notice with the Department and afforded them a reasonable opportunity to correct said noncompliance. Failure to correct said noncompliance after the issuance of a written notice by the Department shall render this Waterways License void and the Commonwealth may proceed to remove or cause removal of any structure or fill authorized herein at the expense of the Licensee, its successors and assigns as an unauthorized and unlawful structure and/or fill. 6. The structures and/or fill authorized herein shall be maintained in good repair and in accordance with the terms and conditions stated herein. 7. Nothing in this Waterways License shall be construed as authorizing encroachment in, on or over property not owned or controlled by the Licensee, except with the written consent of the owner(s)thereof. 8. This Waterways License is granted subject to all applicable Federal, State, County, and Municipal laws, ordinances and regulations including but not limited to a valid final Order of Conditions issued pursuant to G.L. Chapter 131, s.40, the Wetlands Protection Act. CONSTRUCTION: 9a. The project shall not significantly interfere with littoral or riparian property owners' rights to access and egress their property from the waterway. All structures shall be set back, at a minimum, at least twenty-five (25) feet from abutting property lines, where feasible. 9b. Structures shall not extend beyond the length of existing piers used for similar purposes; in no case shall the length extend more than %of the way across a water body and shall conform to the square footage requirements as stated in Construction Condition 9a. 9c. Within areas of salt marsh, structures shall be constructed with a minimum height of 4 feet above ground level measured from the bottom of the stringer, and maximum width of 4 feet, or at a 1:1 ratio so as not to have an adverse impact on the salt marsh or aquatic vegetation. Whereas, the width of the pier maybe equal to but not greater than the'height. Any ladders shall be constructed of durable materials, shall be fixed to the pier in such a manner so as not to rest on the marsh, shall have a minimum width of 2.0 feet, and shall have adequate railings extending above the pier/dock decking in order to facilitate safe passage. 9d. When removed, all seasonal structures shall be stored landward of the mean or ordinary high water shoreline, vegetated wetlands, dunes and all wetland resource areas. Said storage shall be in conformance with any applicable local, state or federal requirements. 9e. The float(s) shall be constructed with an appropriate number of piles/pipes, legs or stop blocks attached to the float structural elements in order to maintain at least 24 inches of clearance off the bottom at extreme low tides. 9f. All work authorized herein shall be completed within five (5) years of the date of License issuance. Said construction period may be extended by the Department for one or more one year periods without public notice, provided that the Applicant submits to the Department, thirty (30) days prior to the expiration of said construction period, a written request to extend the period and provides an adequate justification for said extension. DOCKING OF VESSELS: 10a. Motorized vessels shall be moored stern seaward of the float and shall have a draft no greater than that which provides a minimum of one foot clearance from the bottom at extreme low water. Where eelgrass is present, vessels shall not have any adverse affects on eelgrass in the area. License# Page 5 10b. Vessels shall be moored such that they do not become grounded at any tide. 10c. No dredging (including, but not limited to effects of prop wash) is permitted herein. 10d. No boat moored at any dock may block or unduly impede navigation within the waterway or the use of any adjacent dock. COMPLIANCE The Licensee, within sixty (60) days of completion of the licensed project, shall submit a written statement to the Department that the project has been completed in substantial conformance with the conditions and plans of said license, or a copy of the Certificate of Compliance for this project issued pursuant to the Wetlands Protection Act(if the project was previously issued an Order of Conditions or Superseding Order of Conditions under said Act). This License shall be void unless the License and the accompanying plan(s)are recorded within 60 days from the date hereof, in the Registry of Deeds for the said County. Acceptance of this Waterways License shall constitute an agreement by the Licensee to conform with all terms and conditions stated herein. This License is granted upon the express condition that any and all other applicable authorizations required due to the provisions hereof.shall be secured by the Licensee prlor to the commencement of any activity of use authorized pursuant to this License. -�-� — , OR� assDEPrU,SE�ONLY: THE COMMONWEALTH OF MASSACHUSETTS IN WITNESS WHEREAS, said Department of Environmental Protection have.hereunto set their hands on this day of in the year date month year Commissioner Department of Program Chief Environmental Protection THE COMMONWEALTH OF MASSACHUSETTS This License is approved in consideration of the payment into the treasury of the Commonwealth by said— of the further sum of dollars and zero cents ($ .00) Applicant Amount The amount determined by the Governor as a just and equitable charge for rights and privileges hereby granted in the land of the Commonwealth. Boston Approved by the Governor. Governor License No. Approved by Department of Environmental Protection Date: Barnstable, MA MaOS N,zm 5t E O L(kU$ O � w LLne Garretts 6� Property Pond N z Exit G Q O N / mute G n SITE LOCUS �. r._. '`........ 0 IJOT TO SCALE Exastmg`. 0f'� 'Dwelling.) � O PLAN VIEW SCALE: 1" = 89 57'± Deck EL=43.5± Deck EL=43± OhW EL=3G.9± 12'x I P Float 3'x 1 2'Float 3'x 1 2'Float ` x 4"P05T5(TYP.) 711 711 ,711 ,711 tt10F PROFILE (TYP.) o�° LN D yGa SCALE: I" = 1 O' IV L 'L 0 10 20 30 �O .�%Q, 6 4A° SCALE I "= 1 O' s 0/FtlAL. Purpose: Simplified Licensing Plan accompanying petition of: Project Description: Dock * Floats Certification Adjacent Property Owners: In Garrett's Pond At: Barnstable I . Katherine Manni Robert Bancroft County of: Barnstable 2. Varma Sundelin 2 1 Bancroft Circle State of: Massachusetts by Applicant: Robert Bancroft Barnstable, MA 02GG8 Date: 1211411 G Sheet I of I I DEPARTMENT OF ENVIRONMENTAL PROTECTION WATERWAYS REGULATION PROGRAM Notice of License Application pursuant to M. G. L. Chapter 91 Waterways License Application Number X272876 Bancroft Dock Permit NOTIFICATION DATE: [12/31/16] Public notice is hereby given of the application by Robert& Lisa Bancroft to maintain a dock and ramp at 21 Bancroft Circle, Barnstable, MA in Barnstable County. The Department will consider all written comments on this Waterways application received by within 30 days subsequent to the"Notification Date". Failure of any aggrieved person or group of ten citizens or more to submit written comments to the Waterways Regulation Program by the Public Comments Deadline will result in the waiver of any right to an adjudicatory hearing in accordance with 310 CMR 9.13(4)(c). The group of citizens must include no less than five citizens who are residents of the municipality in which the proposed project is located. Additional information regarding this application may be obtained by contacting the Waterways Regulation Program at 617-292-5929. Project plans and documents for this application are on file with the Waterways Regulation Program for public viewing, by appointment only, at the address below. Written comments must be addressed to: MassDEP's Waterways Regulation Program, Southeast Regional Office, 20 Riverside Drive, Lakeville, MA 02347. i �.... Enter your transmittal number 272876 Transmittal Number Your unique Transmittal Number can be accessed online: http://mass.gov/dep/service/online/trasmfrm.shtmi Massachusetts Department of Environmental Protection Transmittal Form for Permit Application and Payment 1. Please type or A. Permit Information print.A separate Transmittal Form BRP WW06 Simplified Ch 91 License must be completed 1.Permit Code:7 or 8 character code from permit instructions 2.Name of Permit Category for each permit permitting of arc existing dock application. 3.Type of Project or Activity 2. Make your check payable to B, Applicant Information - Firm or Individual the Commonwealth of Massachusetts and mail it with a 1. Name of Firm-Or,if party needing this approval is an individual enter name below: copy of this for,to: Bancroft Robert DEP,P.O.Box . 4062,Boston,MA 2. Last Name of Individual 3. First Name of Individual 4.MI 02211. 21 Brancroft Circle 5.Street Address 3. Three copies of Barnstable MA 02668 5089965611 this form will be 6.City/Town 7.State 8.Zip Code 9.Telephone# 10.Ext.# needed. Robert Bancroft Copy 1 -the 11.Contact Person 12.e-mail address(optional) original must accompany your permit application. C. Facility, Site or Individual Requiring Approval Copy 2 must accompany your Bancroft Residence fee payment. 1.Name of Facility,Site Or Individual Copy 3 should be 21 Bancroft Circle retained for your 2.Street Address records Barnstable MA 02668 5089965611 4. Both fee-paying 3.City/Town 4.State 5.Zip Code 6.Telephone# 7.Ext.# and exempt applicants must 8. DEP Facility Number(if Known) 9.Federal I.D.Number(if Known) 10. BWSC Tracking#(if Known) mail a copy of this transmittal form to: D. Application Prepared by (if different from Section B)* MassDEP Bennett Environmental Associates, Inc. P.O.Box 4062 Boston,MA 1. Name of Firm Or Individual 02211 P.O. Box 1743 2.Address Brewster MA 02631 5088961706 Note:For BWSC Permits, 3.City/Town 4.State 5.Zip Code 6.Telephone# 7.Ext.# enter the LSP. David C. Bennett 8. Contact Person 9.LSP Number(BWSC Permits only) E. Permit - Project Coordination 1. Is this project subject to MEPA review? ❑yes ® no If yes,enter the project's EOEA file number-assigned when an Environmental Notification Form is submitted to the MEPA unit: EOEA File Number F. Amount Due DEP Use Only Special Provisions: 1. ❑Fee Exempt(city,town or municipal housing authority)(state agency if fee is$100 or less). Permit No: There are no fee exemptions for BWSC permits,regardless of applicant status. 2. ❑Hardship Request-payment extensions according to 310 CMR 4.04(3)(c). Rec'd Date: 3. ❑Alternative Schedule Project(according to 310 CMR 4.05 and 4.10). 4. ® Homeowner(according to 310 CMR 4.02). Reviewer. 8666 75.00 12/27/16 Check Number Dollar Amount Date Transmittal Form 111016.doc•rev. 1/07 Page 1 of 1 6666 T2/,27/2016 Filing Fees 75.00 -ise ! 75.00 6666 _ 12/27/2016 Filing Fees \ 75.00 I \ � J d i ise 75.00 m 1-800-328-0304 or www.deluxe.conVshop Massachusetts Department of Environmental Protection Provided by MassDEP: -. Bureau of Resource Protection-Wetlands MassDEP File#:003-5422 ' WPA Form 5-Order of Conditions eDEP Transaction#:880061 fl Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 City/Town:BARNSTABLE A. General Information 1. Conservation Commission BARNSTABLE 2.Issuance a. ld OOC b.r- Amended OOC PP ,... . a.First Name ROBERT b.Last Name BANCROFT c. Organization d.Mailing Address 21 BANCROFT CIRCLE,WEST BARNSTABLE e.City/Town BARNSTABLE f. State MA g.Zip Code 02668 4:Property Owner - a.First Name ROBERT b.Last Name BANCROFT c. Organization d.Mailing Address 21 BANCROFT CIRCLE,WEST BARNSTABLE e.City/Town BARNSTABLE f. State MA g.Zip Code 02668 3::ProJect Location , a.Street Address 21 BANCROFT CIRCLE,WEST BARNSTABLE b.City/Town BARNSTABLE c.Zip Code 02668 d.Assessors 215 e.Parcel/Lot# 013 Map/Plat# f.Latitude 41.69123N g.Longitude 70.34834W 6:Propei=tyecorded`at the Registry of Deed for..' .' ;,.,;;. "'.. ... - a.County b.Certificate c.Book d.Page BARNSTABLE 21626 49 � ... ... .... .....:. ...... 7:Date .:.:. s a.Date NOI Filed: 10/6/2016 b.Date Public Hearing 10/18/2016 c.Date Of 11/10/2016 Closed: Issuance: :...:....:..: : 8 Fuia1A` roved Plans arid:Otherpocuments.. :.PP...:.....- ..:...:....:. :... . .:....:...... ... .......... .. _. .:.. a.Plan Title: b.Plan Prepared by: c.Plan Signed/Stamped by: d.Revised Final Date: e. Scale: REVISED SITE BENNETT PLAN ENVIRONMENTAL LINDA J.PINTO,P.E. 10/31/2016 1"=20' ASSOCIATES,INC. B. Findings .. 1 Fdmgs pursuantaoalielVlassaehusetts Wetlands Protection Act .. ........ Following the review of the the above-referenced Notice of Intent and based on the information provided in this application and presented at the public hearing,this Commission finds that the areas in which work is proposed is significant to the following interests of the Wetlands Protection Act. Check all that apply: a. r Public Water Supply b.J7 Land Containing Shellfish c.R-11 Prevention of Pollution d.r-. Private Water Supply e. 1"i Fisheries f. 1✓ Protection of Wildlife Habitat g.n Ground Water Supply h. 1✓ Storm Damage Prevention i. R- Flood Control Page 1 of 10 *ELECTRONIC COPY .Q Provided by MassDEP: Massachusetts Department of Environmental Protection MassDEP File#:003-5422 j Bureau of Resource Protection-Wetlands eDEP Transaction#:880061 City/Fown:BA INSTABLE WPA Form 5-Order of Conditions Massachusetts Wetlands Protection Act M.G.L.c. 131, §40 2 Commission hereby finds the project, as proposed;is .......... ................... ............. ......... ... ..... . .......... ... ........ ... .. .... .. .... ............ ....... Approved subject to: a.V:The following conditions which are necessary in accordance with the performance standards set forth in the wetlands regulations.This Commission orders that all work shall be performed in accordance with the Notice of Intent referenced above,the following General Conditions,and any other special conditions attached to this Order.To the extent that the following conditions modify or differ from the plans,specifications, or other proposals submitted with the Notice of Intent,these conditions shall control. Denied because: b.r The proposed work cannot be conditioned to meet the performance standards set forth in the wetland regulations. Therefore,work on this project may not go forward unless and until a new Notice of Intent is submitted which provides measures which are adequate to protect interests of the Act,and a final Order of Conditions is issued.A description of the performance standards which the proposed work cannot meet is attached to this Order. c.C'The information submitted by the applicant is not sufficient to describe the site,the work or the effect of the work on the interests identified in the Wetlands Protection Act.Therefore,work on this project may not go forward unless and until a revised Notice of Intent is submitted which provides sufficient information and includes measures which are adequate to protect the interests of the Act,and a final Order of Conditions is issued.A description of the specific information which is lacking and why it is necessary is attached to this Order as per 310 CAM 10.05(6)(c). 3.r. Buffer Zone Impacts:Shortest distance between limit of project disturbance and the wetland resource area specified in 310CMR10.02(1)(a). a.linear feet Inland Resource Area;Impacts (For Approvals Oril y) Resource Area Proposed Permitted Proposed Permitted Alteration Alteration Replacement Replacement 4: Bank 8 ..:: :_.: . ..:_: :. 8 0 :0. a linear feet : b.liriear feet c,ainear.feet d.linear.feet. 5.0 Bordering Vegetated Wetland 12 12 0 0 a. square feet b.square feet c. square feet d. square feet . _. 6 11 Land under Waterbodies and Waterways 1 12 1.12. 0 .. ... a square feet b square feet c square feet. .; d.square feet e, c/y dredged f c/y.dredged 7.r Bordering Land Subject to Flooding a. square feet b.square feet c. square feet d. square feet Cubic Feet Flood Storage e. cubic feet f.cubic feet g. cubic feet h. cubic feet : 8 r Isolated Land Subject to Flooding a square feet . b:squarefeet CubicFeet Flood Storage Page 2 of 10*ELECTRONIC COPY Massachusetts Department of Environmental Provided by MassDEP: Protection MassDEP File#:003-5422 Bureau of Resource Protection-Wetlands eDEP Transaction 9:880061 WPA Form 5- Order of Conditions City/Town:BARNSTABLE Massachusetts Wetlands Protection Act M.G.L.c. 131, §40 I c cu:ic feet:;: d.;cub'c:feet e...cubic:.feet:;'.:; f.`.cu6ic.feet 9.f`Riverfront Area a.total sq.feet b.total sq.feet Sq ft within 100 ft c.square feet d.square feet e.square feet f.square feet Sq ft between 100-200 ft g.square feet h.square feet i.square feet j.square feet Coastal Resource AYea.Impacts Resource Area Proposed Permitted Proposed Permitted Alteration Alteration Replacement Replacement 1:0: :Desgnated Port Areas Indicate sie underLand Under.tlie Ocean;.;below`.: 1 l.tr Land Under the Ocean a.square feet b.square feet c.c/y dredged d.c/y dredged ;12:r Barney Beaches Indicate size under Coastal Beaches and/or Coastal Dunes 13.F Coastal Beaches a. square feet b.square feet c. c/y nourishment d. c/y nourishment 141—Coastal-Dunes. . a. square feet :6:square feet c c/y nounshment d,c/y nounshment 15.0 Coastal Banks a.linear feet b. linear feet 16*.rReeky Inteit dal.Sho'fes a::square feet.li>square feet 17.l-Salt Marshes a.square feet b.square feet c. square feet d. square feet 18.1 .Land Under Salt Ponds a square:feet b square feet':: c:`c/y dredged d:.c/y dredged::. 19.r Land Containing Shellfish a.square feet b.square feet c. square feet d. square feet In dicate size:under,Coastal:Banks;inland Bank;.Land:Under the 20 "Fish Runs Ocean,and/or inland Land Under:Waterbodies and:Waterrvays, _.. .... above' c c/y dredged d c/y dredged _...... . _.._.._. .. . ._.... _ :.__.:._ .__..._.._....... ...._....__..... _..... 2 L -Land Subject to Coastal Storm Flowage a.square feet b.square feet Page 3 of 10 *ELECTRONIC COPY i Massachusetts Department of Environmental Provided by MassDEP: LJr , ProtectionMassDEP File#:003-5422 Bureau of Resource Protection-Wetlands eDEP Transaction#:880061 WPA Form 5- Order of Conditions City/Town:BARNSTABLE Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 ....... ......... 22:.. . I'.! Restoration/Enhancement(For Approvals Only) If the project is for the purpose of restoring or enhancing a wetland resource area in addition to the square footage that has been entered in Section B.5.c&d or B.17.c&d above,please entered the additional amount here. a.square feet of BVW b.square feet of Salt Marsh 23 i`Streams Crossing(s) If the project involves Stream Crossings,please enter the number of new stream crossings/number of replacement stream crossings. a.number of new stream crossings b.number of replacement stream crossings C. General Conditions Under Massachusetts Wetlands Protection Act The following conditions are only applicable to Approved projects 1. Failure to comply with all conditions stated herein,and with all related statutes and other regulatory measures, shall be deemed cause to revoke or modify this Order. 2. The Order does not grant any property rights or any exclusive privileges;it does not authorize any injury to private property or invasion of private rights. 3. This Order does not relieve the permittee or any other person of the necessity of complying with all other applicable federal,state,or local statutes,ordinances,bylaws,or regulations. 4. The work authorized hereunder shall be completed within three years from the date of this Order unless either of the following apply: a.the work is a maintenance dredging project as provided for in the Act;or b.the time for completion has been extended to a specified date more than three years,but less than five years, from the date of issuance.If this Order is intended to be valid for more than three years,the extension date and the special circumstances warranting the extended time period are set forth as a special condition in this Order. 5. This Order may be extended by the issuing authority for one or more periods of up to three years each upon application to the issuing authority at least 30 days prior to the expiration date of the Order. 6. If this Order constitutes an Amended Order of Conditions,this Amended Order of Conditions does not exceed the issuance date of the original Final Order of Conditions. 7. Any fill used in connection with this project shall be clean fill.Any fill shall contain no trash,refuse,rubbish, or debris,including but not limited to lumber,bricks,plaster,wire,lath,paper,cardboard,pipe,tires, ashes, refrigerators,motor vehicles, or parts of any of the foregoing. 8. This Order is not final until all administrative appeal periods from this Order have elapsed,or if such an appeal has been taken,until all proceedings before the Department have been completed. 9. No work shall be undertaken until the Order has become final and then has been recorded in the Registry of Deeds or the Land Court for the district in which the land is located,within the chain of title of the affected property.In the case of recorded land,the Final Order shall also be noted in the Registry's Grantor Index under the name of the owner of the land upon which the proposed work is to be done.In the case of the registered land,the Final Order shall also be noted on the Land Court Certificate of Title of the owner of the land upon which the proposed work is done.The recording information shall be submitted to the Conservation Commission on the form at the end of this Order,which form must be stamped by the Registry of Deeds,prior to the commencement of work.. 10. A sign shall be displayed at the site not less then two square feet or more than three square feet in size bearing Page 4 of 10 *ELECTRONIC COPY I 0 Massachusetts Department of Environmental Provided by MassDEP: Protection MassDEP File#:003-5422 t Bureau of Resource Protection-Wetlands eDEP Transaction#:880061 WPA Foram 5- Order of Conditions City/Town:BARNSTABLE Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 the words, "Massachusetts Department of Environmental Protection" [or'MassDEP"] File Number:"003-5422" 11. Where the Department of Environmental Protection is requested to issue a Superseding Order,the Conservation Commission shall be a party to all agency proceedings and hearings before Mass DER 12. Upon completion of the work described herein,the applicant shall submit a Request for Certificate of Compliance(WPA Form 8A)to the Conservation Commission. 13. The work shall conform to the plans and special conditions referenced in this order. 14. Any change to the plans identified in Condition#13 above shall require the applicant to inquire of the Conservation Commission in writing whether the change is significant enough to require the filing of a new Notice of Intent. 15. The Agent or members of the Conservation Commission and the Department of Environmental Protection shall have the right to enter and inspect the area subject to this Order at reasonable hours to evaluate compliance with the conditions stated in this Order,and may require the submittal of any data deemed necessary by the Conservation Commission or Department for that evaluation. 16. This Order of Conditions shall apply to any successor in interest or successor in control of the property subject to this Order and to any contractor or other person performing work conditioned by this Order. 17. Prior to the start of work,and if the project involves work adjacent to a Bordering Vegetated Wetland,the boundary of the wetland in the vicinity of the proposed work area shall be marked by wooden stakes or flagging. Once in place,the wetland boundary markers shall be maintained until a Certificate of Compliance has been issued by the Conservation Commission. 18. All sedimentation barriers shall be maintained in good repair until all disturbed areas have been fully stabilized with vegetation or other means.At no time shall sediments be deposited in a wetland or water body.During construction,the applicant or his/her designee shall inspect the erosion controls on a daily basis and shall remove accumulated sediments as needed.The applicant shall immediately control any erosion problems that occur at the site and shall also immediately notify the Conservation Commission,which reserves the right to require additional erosion and/or damage prevention controls it may deem necessary. Sedimentation barriers shall serve as the limit of work unless another limit of work line has been approved by this Order. NOTICE OF STORMWATER CONTROL AND MAINTENANCE REQUIREMENTS 19. The work associated with this Order(the"Project")is(1) r. is not(2)I subject to the Massachusetts Stormwater Standards.If the work is subject to Stormwater Standards,then the project is subject to the following conditions; a) All work, including site preparation,land disturbance,construction and redevelopment,shall be implemented in accordance with the construction period pollution prevention and erosion and sedimentation control plan and,if applicable,the Stormwater Pollution Prevention Plan required by the National Pollutant Discharge Elimination System Construction General Permit as required by Stormwater Standard 8.Construction period erosion,sedimentation and pollution control measures and best management practices(BMPs)shall remain in place until the site is fully stabilized. b) No stormwater runoff may be discharged to the post-construction stormwater BMPs unless and until a Registered Professional Engineer provides a Certification that: i. all construction period BMPs have been ,removed or will be removed by a date certain specified in the Certification.For any construction period BMPs intended to be converted to post construction operation for stormwater attenuation,recharge,and/or treatment,the conversion is allowed by the MassDEP Stormwater Handbook BMP specifications and that the BMP has been properly cleaned or prepared for post construction operation,including removal of all construction period sediment trapped in inlet and outlet control structures; ii.. as-built final construction Page 5 of 10*ELECTRONIC COPY Massachusetts Department of Environmental Provided by MassDEP: Protection MassDEP File#:003-5422 Bureau of Resource Protection-Wetlands eDEP Transaction#:880061 s W PA Form 5- Order of Conditions City/1own:BARNSTABLE Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 BMP plans are included,signed and stamped by a Registered Professional Engineer,certifying the site is fully stabilized; iii. any illicit discharges to the stormwater management system have been removed,as per the requirements of Stormwater Standard 10;N. all post-construction stormwater BMPs are installed in accordance with the plans(including all planting plans)approved by the issuing authority,and have been inspected to ensure that they are not damaged and that they are in proper working condition;v. any vegetation associated with post-construction BMPs is suitably established to withstand erosion. c) The landowner is responsible for BMP maintenance until the issuing authority is notified that another party has legally assumed responsibility for BMP maintenance.Prior to requesting a Certificate of Compliance,or Partial Certificate of Compliance,the responsible party(defined in General Condition 19(e))shall execute and submit to the issuing authority an Operation and Maintenance Compliance Statement("O&M Statement") for the Stormwater BMPs identifying the party responsible for implementing the stormwater BMP Operation and Maintenance Plan("O&M Plan")and certifying the following:i.)the O&M Plan is complete and will be implemented upon receipt of the Certificate of Compliance,and ii.)the future responsible parties shall be notified in writing of their ongoing legal responsibility to operate and maintain the stormwater management BMPs and implement the Stormwater Pollution Prevention Plan. d) Post-construction pollution prevention and source control shall be implemented in accordance with the long- term pollution prevention plan section of the approved Stormwater Report and,if applicable,the Stormwater Pollution Prevention Plan required by the Natioual.Pollutant Discharge Elimination System Multi-Sector General Permit. e) Unless and until another party accepts responsibility,the landowner,or owner of any drainage easement, assumes responsibility for maintaining each BMP.To overcome this presumption,the landowner of the property must submit to the issuing authority a legally binding agreement of record,acceptable to the issuing authority,evidencing that another entity has accepted responsibility for maintaining the BMP,and that the proposed responsible party shall be treated as a permittee for purposes of implementing the requirements of Conditions 19(f)through 19(k)with respect to that BMP.Any failure of the proposed responsible party to implement the requirements of Conditions 19(f)through 19(k)with respect to that BMP shall be a violation of the Order of Conditions or Certificate of Compliance.In the case of stormwater BMPs that are serving more than one lot,the legally binding agreement shall also identify the lots that will be serviced by the stormwater BMPs.A plan and easement deed that grants the responsible party access to perform the required operation and maintenance must be submitted along with the legally binding agreement. f) The responsible party shall operate and maintain all stormwater BMPs in accordance with the design plans, the O&M Plan,and the requirements of the Massachusetts Stormwater Handbook. g) The responsible party shall: 1.Maintain an operation and maintenance log for the last three(3)consecutive calendar years of inspections,repairs,maintenance and/or replacement of the stormwater management system or any part thereof,and disposal(for disposal the log shall indicate the type of material and the disposal location); 2.Make the maintenance log available to MassDEP and the Conservation Commission("Commission") upon request;and 3.Allow members and agents of the MassDEP and the Commission to enter and inspect the site to evaluate and ensure that the responsible party is in compliance with the requirements for each BMP established in the O&M Plan approved by the issuing authority. h) All sediment or other contaminants removed from stormwater BMPs shall be disposed of in accordance with all applicable federal,state,and local laws and regulations. i) Illicit discharges to the stormwater management system as defined in 310 CMR 10.04 are prohibited. j) The stormwater management system approved in the Order of Conditions shall not be changed without the prior written approval of the issuing authority. Page 6 of 10 *ELECTRONIC COPY Massachusetts Department of Environmental Provided by MassDEP: Protection MassDEP File#:003-5422 Bureau of Resource Protection-Wetlands eDEP Transaction#:880061 WPA Form 5- Order of Conditions City/Town:BARNSTABLE Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 k) Areas designated as qualifying pervious areas for the purpose of the Low Impact Site Design Credit(as defined in the MassDEP Stormwater Handbook,Volume 3,Chapter 1,Low Impact Development Site Design Credits)shall not be altered without the prior written approval of the issuing authority. 1) Access for maintenance,repair,and/or replacement of BMPs shall not be withheld.Any fencing constructed around stormwater BMPs shall include access gates and shall be at least six inches above grade to allow for wildlife passage. Special Conditions: D.Findings Under Municipal Wetlands Bylaw or Ordinance 1.Is a municipal wetlands bylaw or ordinance applicable?r,, Yes f.. No 2.The Conservation Commission hereby(check one that applies] ar DENIES the proposed work which cannot be conditioned to meet the standards set forth in a municipal ordinance or bylaw specifically: 1.Municipal Ordinance or Bylaw 2.Citation Therefore,work on this project may not go forward unless and until a revised Notice of Intent is submitted which provides measures which are adequate to meet these standards,and a final Order or Conditions is issued.Which are necessary to comply with a municipal ordinance or bylaw: b'C APPROVES the proposed work,subject to the following additional conditions. 1.Municipal Ordinance or Bylaw TOWN OF 2. Citation S 2374-S 237-14 BARNSTABLE 3 The Commission orders that all work shall be performed in accordance with the following conditions and with the Notice of Intent referenced above.To the extent that the following conditions modify or differ from the plans, specifications,or other proposals submitted with the Notice of Intent,the conditions shall control. The special conditions relating to municipal ordinance or bylaw are as follows: SEE PAGES 7.1,7.2,AND 7.3 Page 7 of 10 *ELECTRONIC COPY SE3-5422 Name: Robert Bancroft i Approved Plan= October 31,2016 Revised Site Plan by Linda I Pinto,P.E. Special Conditions of Approval I. Preface Caution: Failure to comply with all Conditions of this Order of Conditions may have serious consequences. Consequences may include: issuance of a Stop Work Order; fines; requirement to remove un-permitted structures; requirement to re-landscape to original condition; inability to obtain a Certificate of Compliance, and more. The General Conditions of this Order begin on Page 5 and continue through Page 8. The Special Conditions contained herein and all Conditions require your compliance. H. Prior to the start of work,the following conditions shall be satisfied: 1. Within one month of receipt of this Order of Conditions and prior to the commencement of any work approved herein,General Condition Number 9(recording requirement)shall be complied with. 2. It is the responsibility of the applicant,the owner and/or successor(s)and the project contractors to ensure that all conditions of this Order are complied with. The applicant shall provide copies of the Order of Conditions and approved plans(and any approved revisions thereof)to project contractors prior to the start of work. Barnstable Conservation Commission Forms A and B shall be completed and returned to the Commission Division prior to the start of work. 3. General Condition Number 10(sign requirement)shall be complied with. 4. The Conservation Commission shall receive written notice one(1)week in advance of the start of work. III. The following additional Conditions shall govern the project once work begins: 5. General Conditions,Numbers 13 and 14(changes in plan)shall be complied with. 6. The Conservation Commission,its employees and its agents shall have a right of entry to inspect for compliance the provisions of this Order of Conditions. 7. Unless extended,this permit is valid for three years from the date of issuance. 8. An Amended Order does not change the original date of expiration of this Order of Conditions. Rev.0916 7.1 9. The fire pit that was relocated above the 50-foot buffer and the debris pile shall be removed. 10. The plank out to the beach area and the styrofoam floats shall be removed. 11. All mitigation(meadow seeding)and restoration of the 35-foot buffer shall be carried out. Advance consultation with the Conservation Agent required for species and densities. Once completed,the planting shall be retained. Replacement shall be provided for specimens failing to thrive. Temporary irrigation may be provided. 12. The restoration planting area in the 35-foot buffer,as shown on the approved plan,shall be allowed to naturalize. It should not be irrigated(temporary irrigation only),fertilized,treated with herbicides or pesticides,mulched,* or weeded. Exceptions shall be made for watering by hand during drought conditions and management of invasive species without herbicides. *(Mulch may only be used until plants become established). Should mitigation plantings grow to obstruct a view corridor,prior approval of Conservation staff will be necessary before pruning or lowering height may occur. 13. The meadow may be mowed once per year,between February and April 15t'. 14. Invasives may be hand-pulled within the 35-foot buffer restoration area. 15. Monitoring reports for mitigation/meadow and planting restoration area shall be submitted by a landscape professional once annually for a period of three years. Reports may commence after a growing season. 16. No reconstruction of this pier is allowed under a Form M(maintenance). When the pier reaches the end of its useful life,reconstruction of a new pier will require the filing of a new Notice of Intent application, complying with the Commission's pier and dock guidelines,including removal of the concrete slab. 17. A half-rail fence(or approved alternative)shall be constructed and maintained along the 35-foot buffer line. IV. After all work is completed,the following condition must be promptly met: 18. At the completion of work,or by the expiration of this Order,the applicant shall request in writing a Certificate of Compliance for the work herein permitted. Barnstable Conservation Commission Form C shall be completed and returned, along with the request for a Certificate of Compliance and appropriate fee. Where a project has been completed in accordance with plans stamped by a registered professional engineer,architect,landscape architect or land surveyor,a written statement by such a professional shall be submitted,certifying substantial compliance with the plans,setting forth what deviation(s),if any,exists with the record plans approved in the Order. This statement shall accompany the request for a Certificate Rev.0916 7.2 e' of Compliance and fee,along with an updated sequence of color photographs of the undisturbed buffer zone. Rev.0916 7.3 LlMassachusetts Department of Environmental Provided by MassDEP: Protection MassDEP File##:003-5422 I Bureau of Resource Protection-Wetlands eDEP Transaction#:880061 WPA Form 5-Order of Conditions city/Town:BARNSTABLE Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 E. Signatures This Order is valid for three years from the date of issuance,unless otherwise specified pursuant to General Condition#4.If this is an Amended Order of 11/10/2016 Conditions,the Amended Order expires on the same date as the original Order of 1.Date of Original Order Conditions. Please indicate the number of members who will sign this form.This Order must 6 be signed by a majority of the Conservation Commission. 2.Number of Signers The Order must be mailed by certified mail(return receipt requested)or hand delivered to the applicant.A copy also must be mailed or hand delivered at the same time to the appropriate Department of Environmental Protection Regional Office,if not filing electronically, and the property owner,if different from applicant. Signatures: PETER SAMPOU FAT PIU LEE JOHN E.ABODEELY LOUISE R.FOSTER SCOTT BLAZIS DENNIS R-HOULE 1 J by hand delivery on 0 by certified mail,return receipt requested,on Date Date F.Appeals The applicant,the owner,any person aggrieved by this Order,any owner of land abutting the land subject to this Order, or any ten residents of the city or town in which such land is located,are hereby notified of their right to request the appropriate MassDEP Regional Office to issue a Superseding Order of Conditions.The request must be made by certified mail or hand delivery to the Department,with the appropriate filing fee and a completed Request for Departmental Action Fee Transmittal Form,as provided in 310 CMR 10.03(7)within ten business days from the date of issuance of this Order.A copy of the request shall at the same time be sent by certified mail or hand delivery to the Conservation Commission and to the applicant,if he/she is not the appellant. Any appellants seeking to appeal the Departments Superseding Order associated with this appeal will be required to demonstrate prior participation in the review of this project.Previous participation in the permit proceeding means the submission of written information to the Conservation Commission prior to the close of the public hearing, requesting a Superseding Order,or providing written information to the Department prior to issuance of a Superseding Order. The request shall state clearly and concisely the objections to the Order which is being appealed and how the Order does not contribute to the protection of the interests identified in the Massachusetts Wetlands Protection Act Page 8 of 10 *ELECTRONIC COPY Massachusetts Department of Environmental Protection Provided by MassDEP: Bureau of Resource Protection - Wetlands SE3-S�G/Z 2 WPA Form 5 ® Order ®f Conditions MassDEPFile# Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 eDEP Transaction# Barnstable City/Town E. Signatures Important:When This Order is valid for three years, unless otherwise specified as a special NOV U 0 2016 filling out forms condition pursuant to General Conditions#4,from the date of issuance. 1.Date of Issuance on the computer, . use only the tab Please indicate the number of members who will sign this form. key to move your This Order must be signed by a majority of the Conservation Commission. 2.Number of Signers cursor-do not use the return The Order must be mailed by certified mail (return receipt requested) or hand delivered to key the applicant. A copy must be mailed, hand delivered or filed e�c onica Ily at the same time with the appropriate MassDEP Regional Office. c Signatures: ZfI4 ❑ by hand delivery on by certified mail, return receipt requested, o`!®V t 0 2016 Date Date F. Appeals The applicant, the owner, any person aggrieved by this Order, any owner of land abutting the land subject to this Order, or any ten residents of the city or town in which such land is located, are hereby notified of their right to request the appropriate MassDEP Regional Office to issue a Superseding Order of Conditions. The request must be made by certified mail or hand delivery to the Department, with the appropriate filing fee and a completed Request of Departmental Action Fee Transmittal Form, as provided in 310 CMR 10.03(7) within ten business days from the date of issuance of this Order. A copy of the request shall at the same time be sent by certified mail or hand delivery to the Conservation Commission and to the applicant, if he/she is not the appellant. Any appellants seeking to appeal the Department's Superseding Order associated with this appeal will be required to demonstrate prior participation in the review of this project. Previous participation in the permit proceeding means the submission of written information to the Conservation Commission prior to the close of the public hearing, requesting a Superseding Order, or providing written information to the Department prior to issuance of a Superseding Order. The request shall state clearly and concisely the objections to the Order which is being appealed and how the Order does not contribute to the protection of the interests identified in the Massachusetts Wetlands Protection Act(M.G.L. c. 131, §40), and is inconsistent with the wetlands regulations (310 CMR 10.00). To the extent that the Order is based on a municipal ordinance or bylaw, and not on the Massachusetts Wetlands Protection Act or regulations, the Department has no appellate jurisdiction. wpa5sigs.doc• rev.02/25/2010 Page fof Lo f Massachusetts Department of Environmental Provided by MassDEP: LlA ProtectionMassDEP File#:003-5422 Bureau of Resource Protection-Wetlands eDEP Transaction#:880061 Wl'A Form 5-Order of Conditions City/Town:BARNSTABLE Massachusetts Wetlands Protection Act M.G.L.c. 131, §40 (M.G.L.c. 131, §40),and is inconsistent with the wetlands regulations(310 CMR 10.00).To the extent that the Order is based on a municipal ordinance or bylaw,and not on the Massachusetts Wetlands Protection Act or regulations,the Department has no appellate jurisdiction. G.)Recording Information This Order of Conditions must be recorded in the Registry of Deeds or the Land Court for the district in which the land is located,within the chain of title of the affected property.In the case of recorded land,the Final Order shall also be noted in the Registry's Grantor Index under the name of the owner of the land subject to the Order.In the case of registered land,this Order shall also be noted on the Land Court Certificate of Title of the owner of the land subject to the Order of Conditions.The recording information on this page shall be submitted to the Conservation Commission listed below. BARNSTABLE Conservation Commission Detach on dotted line,have stamped by the Registry of Deeds and submit to the Conservation Commission. --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- To: BARNSTABLE Conservation Commission Please be advised that the Order of Conditions for the Project at: 21 BANCROFT CIRCLE,WEST BARNSTABLE 003-5422 Project Location MassDEP File Number Has been recorded at the Registry of Deeds of. County Book Page for: Property Owner ROBERTBANCROFT and has been noted in the chain of title of the affected property in: Book Page In accordance with the Order of Conditions issued on: Date P,k 301 10 Ps 148 61276 If recorded land,the instrument number identifying this transaction is: Instrument Number If registered land,the document number identifying this transaction is: Dpcument Number Page 9 of 10 *ELECTRONIC COPY Massachusetts Department of Environmental Provided by MassDEP: Protection MassDEP File#:003-5422 Bureau of Resource Protection-Wetlands eDEP Transaction#:880061 WPA Form 5-Order of Conditions City/Iown:BARNSTABLE Massachusetts Wetlands Protection Act M.G.L. c. 131, §40 Signature of Applicant Rm onizoio Page 10 of 10*ELECTRONIC COPY BARN STA5"lE REGISTRY OF DEEDS John F. Meade, Register 03/25/2011 19:02 5087785010 TUPPERCO PAGE 02/02 V� r6NN) TUPPER k CONSTRUCTION CO. PLC 79B MID-TECH DRIVE,WEST YARMOUTH,MA 02673 � PHONE: 508-778-0111 FAX: 508-778-5010 -\ ` WVVW,TUPPERCO.COM \V 4/10/2013 Town of Barnstable �G Thomas Perry CBO 200 Main Street Hyannis; Ma 02601 (508) 790-6230 fax Re: Insulation Permits C w O C.0 '3 0 C�p Dear Mr. Perry o n . This affidavit is to certify that all work completed for permit appl' ation w # 201302095 Issued on 4/9/2013, has been inspected by a certified Building Performance Institute (BPI) inspector. . All work performed meets or exceeds Federal and State requirements. Sincerely, Richard Tupper License # CS-69058 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map - Parcel 6 Application # Health Division 2013 AFC -4 APB 8` _3 2 Date Issued Conservation Division Application F Planning Dept. Permit Fee DlVisi l Date Definitive Plan Approved by Planning Board Historic - OKH Preservation / Hyannis Project Street Add r s t Village I t Z Owner Address Telephone 'Permit Request 0 °Square feet: 1 st floor: existing proposed 2nd floor: existing proposed ' Total new Zoning District Flood Plain Groundwater Overlay 'Project Valuation Construction Type i Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full 0 Crawl ❑Walkout 0 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 0 Oil ❑ Electric ❑ Other Central Air: 0 Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # L Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name ne Numberh Tele Telephone T P�f ee Address 7 N License # Home Improvement Contractor# Worker's Compensation ALL CONSTRU EB FROM THIS PROJ CT WILL BE TAKEN TO �TULTING ;�p �"k. SIGNAT DATE FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED - f� MAP/PARCEL NO. j ADDRESS VILLAGE OWNER ,ts DATE OF INSPECTION: _ FOUNDATION. .. FRAME INSULATION FIREPLACE, ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL z, FINAL BUILDING DATE CLOSED OUT t t ASSOCIATION PLAN NO. Bancrofi'137030 032813.pdf http://riseportal.com/capecod/tupperconst/Lists/Schedule/Attachments/... r OWNER AUTHORIZATION FORM L r -� (Owner's Name) ' owner of the property located at (Property Address) Lp (Property Address) ' hereby authorize Tage<- /0 (Subcont ' an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building permit and to perform work on my property. Owner's Slgnat v N./aV4:�- Date j 4 of 8 3/18/2013 9:07 AM t3UILDINU PEHFUHMANCE IN 111U'Ci~, INC 1 Massachusetts-Department of Public Safety ~ 4 107 Hamvs Road,Suite 110 '' Hoard of Building Regulations and Standards Matta,NY 12020 h COnstruction Supen isor (877)274-1274 f License: CS-069058 . wvrww.bpi.cam }; RICHARD S TUP.?tR 79 B M il k R t G { WEST VARMOVM MA 02 73 i Richard Tupper ® BPt tD#-,5O4094o CERTIFIED PROFESSIONAL `%.�... Jy h��sb<s Expiration (SEE REVERSE SIDE FOR DESIGNATIONS AND 0MRATION DATES) Commissioner 12/31/2014 t i ��T �iA4C�L4: Y 4 ,� - t .,.. gfiiecoCGonsumarptfnirs&.B sinecxRegulrtion t R6 1+ »40fisidtil5„lfltt Woad ,HOME IMPROVEMENT CONTRACTOR � .� Regis - 845 Typo: E r tt 6hW 4 Individual ; � w RI CHAR PEt2# G `yy` 41.id A, Tupp�� Y xf , „x z «; RIC D TUPPER 3Tupper' O�astuct�Qnr rx� A tt 29 Ro rt Drive uUtl;�Sa� � r ` , W.YAR 0 TH,MA 3 :, undersecretary ilAerxt � 1:5819 Eicpti3012d13 . Dec. 19. 2012 4:37PM No. 8524 P. 1/2 AGUMUTp CERTIFICATE OF LIABILITY INSURANCE YV}DATE 12/19/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. it SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certaln 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 NAME: Lora Lowe Southeastern Insurance Agency, Inc. arc°.NoE#: (508)997-6061 cNe; (508)990-2731 439 State Rd. EMAIL ADDRESS: P.O. Box 79398 CUSTOMS ID I• N. Dartmouth, MA 02747 INSURER(S)AFFORDING COVERAGE NAICI INSURED INSURERA: Arbella Protection Insurance Tupper Construction Co LLC INSURERS: AEIC INsuRERc: CNA Surety 27 Roberta Drive INSURERD: West Yarmouth, MA 02673 INSURERE: _ INSURER F: COVERAGES CERTIFICATE NUMBER: 12/13-2 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMIDD MMIDD I LIMITS GENERAL LIABILITY 8S0000874311/01/2012 11/01120131 EACH Occx,'RI,ENCE $ 1,000,00 X 'COMMERCIAL GENERAL LIABILITY 'uRENTED $ 100.000 - �- 1 PREMISES(Ea occunerxe} aEEO EXP(An one ) $ 5,000 � I CiAiMS+N�DE �OCCUR ;t Y person A PERSONAL a ADV INJURY $ 1,000,000 j I GENERAL AGGREGATE $ 2,000,000 rGE1L AGGREGATE LIMTr APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 POLicy F ic-CT LOC I $ AUTOMOBILE LIABILITY 56662400002 12/01/2012 1210112013 CGMBINEO SINGLE LIMIT (Ea acaaa t) $ 1,000,000 I ANY AUTO BODILY INJURY(Per person) $ -- I ALL OWNED AUTOS BODILY INJURY(Peracadeni) $ A X ;SCHEDULED AUTOS —_ ___._........._............---_...-- .� PROPERTY OHMAGE X 'HIREDAUTOS (r'eracadent) $ INC X 14014 OA'NED AUTOS OS _ $ - --- I $ UMBRELLALIAB HOCCUR I EACMiOCCURRENCE $ EXCESS LIAR CLAIMS-MADE ( ' AGGREGATE $ HDEDUCTIBLE $ RETENTION WORKERS COMPENSATION I ; WCC50OSS9301200 10/03/2012 10103/2013 X T RYLMITS': X ER j AND EMPLOYERS'LIABILr1Y YIN i ANY PROPRIETOPIPARTNER(EXECUTIVE � I RICHARD TUPPER IS EL.EACH ACCIDENT _ $ S00,00 B 0:fICER/b1EM8EP,EXCLUDED) �_J NIA I LUDED FOR WC COVERAGEE L DISEASE•EA EMPLOYES$ 500,000 (Mandatory In NH) _ 4 i seues,descnbe under i E L.DISEASE-POLICY LIMIT T:; 500,000 !PTION OF OPERATIONS Oelow Oond for theft of money & or 71069913 02/28/2012 02/28/2013 Limit of $10,000 C property. DESCRIFT1014 OF OPERATIONS I LOCATIONS$VEHICLES(Attach ACORD 101,Addilional Remarks Schedule,If more space Is required) ill.julio@csgrp.com CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Conservation Services Group Attn: Bill Julio AUTHORIZED REPRESENTATIVE 50 Washington Street We thorough, MA 01581 Lora Lowe O 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 UT, www,mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name (Business/Organization/hmdividuap: Tupper Construction Co. , LLC Address: 79B Mid Tech Drive City/State/Zip: West Yarmouth, MA 02673 Phone#: 508-778-0111 Are you an employer?Check the appropriate box: Type of project(required): 1.21 :1 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.Eli am a sole proprietor or partner- listed on the attached sheet. + ❑ 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.❑ 1 am a homeowner doing all work right of exemption per MGL I i.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§](4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' 13.❑Other comp. insurance required.] "Any applicant that checks box of 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 subcontractors 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: AE I C Policy#or Self-ins.Lic.#: W,CC 5005593012012 Expiration Date: 10/0 3/2 013 �/� Job Site Address: J/ 2-dA V t— �d . /�, c7/1/Z-4�_City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure covet-age as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under d ns and penalties of perjury that the information provided above is true and correct. Si nature: Date: l3 d l Phone#: 5O _ 7 -014(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#: