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0027 KALWEIT ROAD
a i I b ONO. 52 1/3 ORA ESSELTE o°io ALTERNATIVE WEATHERIZATIO•N �. Date: ! �" Town-of Barnstable 200 Main St H annis,MA 02601 :;." - :<� " ::i..� ••.J,S:•.• ,`•:`r,.ti:t.::,:gip_„ `•Y•ir"J::,': ir:�L::�,^x^�.,.. i'•' 3' :• el�! .:�z;;: ReiPermit# — �l 1 °A_:�- "Villag Y; Yn=a;y:rJz'-[-"v;:��jy. 'Z� „�r�•�ki��..,..enr.:;,*!r;G• ";'^-, $,L—.3'���f'•r,•:'+.':.r^ .'!•,7'r.:A ••>,..55.,,,:'s5.r-i.�,�.�:�:. ••�"� `Y ��?:j'��ti. :•.;ti:r:c'�: 't :A ,a;.:1;�,4:Jf'.0 v�5:�':1 .:'/:.;,.?e�•1. •''6'`, 'r: .(:i•.: '[,�•. .1`..r: �a:> ''"�' �7.:�. >•.::.�i..,;r.:,,1.:."die;; insulation/weatM... ark at L ':i!•; :.Y� ": r"'-trnv :;4r -•5i+: :•�:• .. �t�� :r.._,._.; sC:'f:�7:r:�. r; �„ C,; „�. :'(•!:'�-r� iA! ..Y., .:�(�:`.':i.: -.r,1.r'•. r '"•`Nl.:�,,,' :)• <..n 7 :� ,c ,c4�,v�'^.l T' (t`' r -:;.lC.:S`� ,4':.,•"•,,��� k�eeu coxnpleti' 1dtnCe wlt} � x�.= .5",S.�y. .yLu 'R. .r?+o-•'r ,� y cH•.,' �2°:;;:p`-. ?SP. E_::; '• (' o.'�:.: ..i�� yOr'.a6i I,i•^. •��•'.� :.G�L%G,•[..yy ��:6rix^• :x' C. 'e;�!Yip'e.Y7% ,:iy'��};t;lij•i./.. `''G n'��i: ,fib'.• _4'.. •� •'�-.C:�y:f;1;�'�' `:��2•.q^ �.:f�'.1::, ��,fi`'!: .r:. �c:i '!:.` S'...,1.. 1�.�,ILT{li:�:v:'+,:':::t, ... ...<..:�i...:i'r',:��'i •'V'_•\. i':•pl, ),5'!1:•.:1�•sJ:' +i1: j'w�4�''���:.'. ..4...1'r...r;��:.'�::'_�:^::��:. .:C':�_.<i" >n r •:�•:.<.a^<.ls:;�hKSY..:; �•';i!: `.r;F� "s,�. 'i��.o-";.\:'.;:i=::::::.�'•� Regair�s�;�-'n-•�: �Y'.;,-:., 2:P'��5`�`i'c 1��_ fi f `�1.. .v,_,, ,w{w_`•' ' . N. .1',.,.,!'»j' �:�::,�u:;•;:,:•`' `'Y'''...; cam'"•�"Z•..,;�;::�; ., ''�' rye!'�w; :.o�%z• _���,%•.�:�'.{''""� ,'•r'•'' Timothy Cabral, President ••CSL-105454 58 DICKINSON STREET I FALL RIVER,,�.02721 ( .(508).5b7-4240 •.1. ALT>~RNATIVEWDAGHF.RVATIOMgOM-AIL•COM', 1�� 3�0 � p�c�erv�� n� � � � o�� �� �,ea'L �, /_ IT 1 � -, r :.Application number................................................ lam, I Date Issued.......�.��27, l.fi s DEC 2 7 M.j Building Inspectors Initials............ ..:................... 110 -0 1 -6 OWN i ►'t 6ARNSIABEF ,Map/Parcel ... ................. .... TOWN OF'BARNSTABLE i .. wED TED,PERiV1IT APPLICATION: ROOF/SMING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: e�?l NUMBER= ; ' ` `:' -STREET - `. _VILLAGE Owner's Name: Pill Phone Number &/7—U l CI - 2,7 V 7 Email Address: Cn!% V/ yam/ @ ')'1'IGa�S , . Cell Phone Number nef_ w Project cost$ ��(O (! Check one. Residential f Commercial r�,OWNER'S AUTHORIZATION As owner of the above property I hereby authorize fir^ 07� to make application for a building permit in accordance with 78 MR Owner Signature: Date: TYPE OF WORK ❑ .Siding ❑ Windows(no header-change)..#:k• n Insulati6rdWeatherization 1. ❑ Doors (no header change)# Commercial Doors-require-an.inspector.'s keview: ❑ Roof(not applying more than 1•layer of shingles) Construction Debris will be going to CONTRACTOR':S INFORMATION _ A r ° S$ . . Contractor's name -.. ._ T�L 1 // Home Improvement Contractors Registration(if applicable)# /�J'G �� (attach copy) Construction Supervisor's License# (attach copy) @Gyylal�- C,{177� _ Email of Contractor &HW,U)P _ ��. Phone number OP 57o9-MY0 ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER...........................................................t *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s) of each tent If food is being served at your event please obtain a Health Department approval between.the hours of 8:00am--9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval *WOOD/COAL/PELLET STOVES * . Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APP IC 'S SIGNATURE Signature Date /°2 All permit applications are subject to a building official's approval prior to issuance. v° Town of Barnstable aR Building Department Services 1639. e� Brian Florence,CBO Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us I Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, Larry Henry as Owner of the subject property AIfffllgkku)PAALr;hereby authorize ZA- �C to act on my behalf, in all matters relative to work authorized by this building permit application for: 27 Kalweit Drive West Barnstable (Address of Job) Signature of Ow/her S nature of Applicant cc I 0 !r Print Name Print Name Date The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02114-2017 1r,zwww mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. y TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Leeibly Name (Business/Organization/Individual): ALTERNATIVE WEATHERIZATION, INC. Address: 2 LARK STREET City/State/Zip: FALL RIVER, MA 02721 Phone#:508-567-4240 Are you an employer?Check the appropriate box: Type of project(required): 1.�✓ I am a employer with 16 employees(full and/or part-time).* 7. New construction 2.M I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling any capacity.[No workers'comp.insurance required.] 9. ❑Demolition 3.[]I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 10 Q Building addition 4.FJ I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers'compensation insurance or are sole 1 l.M Electrical repairs or additions proprietors with no employees. 12.[:]Plumbing repairs or additions 5.M I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[]Roof repairs These sub-contractors have employees and have workers'comp.insurance.- 6.7 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E✓ Other INSULATION 152,§1(4),and we have no 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 Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: LIBERTY MUTUAL INSURANCE Policy#or Self-ins.Lic.#: XWO(19)58867158 /` Expiration Date:6/8/19 Job Site Address: d�2 .�Ll � City/State/Zi 1)7,4 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration d e). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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 S250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the D1A for insurance coverage verification. I do hereby certify u d ain a p lti s f perjury that the information provided above is true and correct. Sip-nature: Date: Phone#:508-567-4240 Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: / , ® DATE(MMIDD/YYYY) A6► o CERTIFICATE OF LIABILITY INSURANCEF��' 06/11118 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(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER NAME: PHONE 508-677-0407 AIC No: 508-677-0409 Anthony F.Cordeiro Insurance Agency -(A/C.No. o Ext 171 Pleasant Street ADDRESS: HSouza@Cordeirolnsurance.com Fall River,MA 02721 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: Liberty Mutual INSURED INSURER B: Ohio Security Alternative Weatherization INSURERC: Ohio Casualty 2 Lark St INSURER D: Fall River,MA 02721 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMIDD/YYYY IY MMIDDYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,000 CLAIMS-MADE Fx_�OCCUR PREMISES Ea occurrence S 300,000 MED EXP(Any one person) S 15,000 A Y Y BKS58867158 06/08/18 06/08/19 PERSONAL BADVINJURY S 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S 2,000,000 JECT LOC PRODUCTS-COMP/OP AGG S 2,000,000 POLICY PRO-R OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $Ea accident 1,000,000 ANY AUTO BODILY INJURY(Per person) S B OWNED X SCHEDULED Y BASS8867158 06/08/18 06/08/19 BODILY INJURY(Per accident) S AUTOS ONLY AUTOS X HIRED NON-OWNED PROPERTY DAMAGE S AUTOS ONLY X AUTOS ONLY Per accident S X UMBRELLA LIAB X OCCUR EACH OCCURRENCE s 1,000,000 A EXCESS LIAB CLAIMS-MADE Y Y US058867158 06/08/18 06/08/19 AGGREGATE $ 1,000,000 , DED RETENTIONS S WORKERS COMPENSATION AND EMPLOYERS'LIABILITY STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE Y 1 N E.L.EACH ACCIDENT $ 500,000 C OFFICER/MEMBER EXCLUDED? n1 N/A XWO58867158 06/08/18 06/08/19 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE S 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Action Inc and NGRID,USA its direct and indirect parents,subsidiaries and affiliates is added as an Additional Insured for General Liability on a Primary&Noncontributory basis per the terms and conditions of form CG2001 (04/13),for Ongoing Operations per the terms and conditions of form CG2010(04/13),for Completed Operations per the terms and conditions of form CG2037(04/13)and Waiver of Subrogation applies per the terms and conditions of form MEGL0241-01 (04-11) Additional Insured for Automobile Liability applies per the terms and conditions of form SCA005(02/16) Excess Liabilitv is a following form. CERTIFICATE HOLDER CANCELLATION i SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN NGRID USA ACCORDANCE WITH THE POLICY PROVISIONS. 40 Sylvan Road Waltham,MA 02451 AUTHORIZED REPRESENT f 1 I ©19gt-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD ftka;i 114sel<t;r,De.paiti tent of Public Sttliety ! � }e#t�Q itl tlt 2 fliZttClllS almw St 3ldifto. Lkthse;tS-405453 Construction Supervisor I71Y1r01 fi�itY♦`,CABf sAa�:'t '?q•+.: 14 .�• r 68 tll�:tCWSON Srl r FALL'RIVER MA 001 ` TCt3#rtrrli sicitrt�f 0810912019 '-61101MjW?J11.u2,ea 11MI i f 4 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improveme i:-6ntractor Registration { - Type: Corporation '._.._� ===J _ r Registration: 175683 ALTERNATIVE WEATHERIZATION, INC. 2 LARK ST _ 'i Expiration: 05/2812019 -_..Y �.I FALL RIVER,MA 02721 = { Update Address and return card. Mark reason for change. SC::. .. 2�;.".•tea•7. ---- Z.Address.-n RerewaL0 P—Dinympnf n Losff.ca-rL4._.. . " Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only ` TYPE:Corporation before the expiration date. If found return to: Registration R Exoiration Office of Consumer Affairs and Business� Regulation , �r1756t8 05/28/2019 10 Park Plaza-Suite 5170 ALTERNATIVE WEXTHERIZATION,INC. n,MA 02116 TIMOTHY CABRAL 2 LARK ST r FALL RIVER,MA 02721 Undersecretary ti7v out si�ature I - N r Z3g 7 7 , 1 • yF�" 2� 4�' 47:t "l h N n �� N r � ' I � I i I certify that this property is located in Flood Hazard Zone C ( out- side the 500 year flood) as identified by the Department of Housing and Urban Development (HUD) . Date/ U—/4/ e l ff ti.. „ CERTIFIED PLOT PLAN LOCATION .B�9ZvST,g4G3 CL✓C.�r� SCALE . .� .-..'�' DATE ! �1iL C 179Z Reg,: Land Surveyor PLAN REFERENCE B ?Alt . Z-q"J�„ . slb�i.� c•�.� �L.E',rC. Zo 3 . . . . . . . . . . . . . . : . . . . . . . . . . . . .. . . . . . . . . I certify to its title insurance company that there are no visible encroachments I CERTIFY THAT THE � �?^�'� D�✓L-zl�•✓G or easements except as shown and that this SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN HEREON AND THAT IT CONFORMS TO THE plan was prepared under my immediate SETBACK REQUIREMENTS OF THE TOWN OF supervision. QfI1?!'!�?T'IB4E... . . . .WHEN CONSTRUCTED. DATE /�i ,l�iaC 41,V,--7 7- �1•r C"A A• VETi��9�,-A '--r REGISTERED LAND SURVE R r TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map ! Parcel - Permit# Jb 9*0 Health Division Date Issued 9 Conservation Division Mo..9°I 12 - Fee Tax Collector �� �%Aftft SEPTIC SYSTEM M Treasurer �l2'1 �� INSTALLED IN COMP MUST BE WITH LIANCE PlanningDept. TITLE 5 p ENVIRONMENTAL CODE AND Date Definitive proved by Planning Board OWN REGULATIONS Historic-OKH Preservation/Hyannis Project Street Address 9- Village lam_ 49ZZ2- C62 Owner 4-ftf (C 16- <4 eve, fi Address S Uh Telephone iJ — Z Permit Request 4>?D Xa2 Square feet: 1 st floor: existing proposed LJOD 2nd floor:existing �'� proposed Total new Estimated Project Cost��20 'Zoning District Flood Plain Groundwater Overlay 1 9 Y Construction Type Lot Size y�,600 Grandfathered: ❑Yes O No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family O Multi-Family(#units) Age of Existing Structure yr_S Historic House: O Yes ®No On Old King's Highway: ®Yes ❑No Basement Type: �ull 0 Crawl O Walkout ❑Other Basement Finished Area(sq.ft.) •xs_?o Basement Unfinished Area(sq.ft) 74—0lo Number of Baths: Full: existing oN e- new Half:existing o tee; new ew Number of Bedrooms: existing n Total Room Count(not including baths): existing new First Floor Room Count y Heat Type and Fuel: ❑Gas at'iil ❑ Electric ❑Other Central Air: ❑Yes B o Fireplaces: Existing Iry e- New Existing wood/coal stove: es O No Detached garage:O existing 0 new size Pool:O existing ❑new size Barn:O existing Cl new size Attached garage:O existing O new size Shed:O existing ❑new size Other: Zoning Board of Appeals Authorization O Appeal# Recorded O Commercial Cl Yes (R o If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION Name Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE ✓ Q FOR OFFICIAL USE ONLY MIT N �� V / `PER .O ..tea - :;�•.,� , DATE ISSUED .. " MAP/PARCEL NO.' ADDRESS VILLAGE f -- OWNER e DATE OF INSPECTION: - r FOUNDATION y FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUp1'^ FINAL _ Y GAS: ROUF'H-- FINAL nfn FINAL BUILDING to � Q R.✓ - R n 0 1 DATE CLOSED OUT n i ASSOCIATION PLAN NO.}- N / , m m TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel' Application # Health Division b �D Date Issued Conservation Division .Application Fee C�? Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic ' OKH Preservation/ Hyannis Project Street Address W �► �r Village o e -r go r (o6r Owners--n�u rl I W °�=�� Address Telephoned— � Permit Request die�� � ?� �� ; t"" e= gL�5' zcn /) 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 0 No If yes, attach supporting documentation. Dwelling Type: Single Family '.❑ Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor ROD Count= o Heat Type and Fuel: ❑ Gas ❑Oil ❑ Electric ❑ Other x, Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove❑Y4 ❑ No 03 Detached garage: El existing ❑ new size Pool: ❑ existing ❑ new size _ Barn: ❑ existing �ewpize_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use ---- - _ Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) NameT Telephone Number Address fei�' )1 the License # Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE /�3— 1 k FOR OFFICIAL USE ONLY fb AAPLICATION# s DATE-ISSUED h MAP_/PARCEL NO. -ADDRESS-., VILLAGE OWNER 4 a f DATE OF INSPECTION: } FOUNDATION 's FRAME :INSULATION.JI FIREPLACE e J ELECTRICAL: ROUGH FINAL :z '. PLUMBING: ROUGH FINAL ` '3 GAS:a� � ': ROUGH FINAL - } u;mfFiIN'AL BU1_LD.ING t $._-DATE.CL-OSED.OU.T. _ • _ ASSOCIATION PLAN NO. r The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 •:•�• www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lelxibly GNaMe(Business/Organizadon/Individual): ' O Address: °`��q �,�� e. r►y� City/State/Zip: trlg))q, R Phone.#: Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with _ T�,�a general contractor and I employees(full and/or part-.time).* have hired the sub-contractors 6. ❑New construction 2.El I am a sole proprietor or partner-' listed on the'attached sheet. T. Q Remodeling ship and have no employees These sub-contractors have g• . Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp.. right of exemption per MGL. 12.❑Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant.that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must providt:their workers'comp.policy number. Iam an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob 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 crimi ial 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 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 h sand penalties of perjury that the information provided above is true and correct PipS ture Date: 6� 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.BuiIding Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: Information and Ins' fir, 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 compHance�%zth 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-cont�actor(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"(he applicant should write"all locations in__(city or town).".A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to 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: The Commonwealth of Massachusetts Departumt of Industrial Accidents Office of Investigations. 600 Washington Street Roston, MA102111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 11-22-06 www.mass.gov/dia r t►,F Town of Barnstable . pf r� - o Regulatory Services w BARNSrABr E Thomas F. Geiler,Director MASS. 1639 a�e� Building Division TfD MAC Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: -2 —7 t-j 80yra,�u k I V_ number �C street (, village ..HOMEOWNER": `/��� �QI►t��, ` �SO�~�6 � 77 �3_VrZQO �c7p� name home phone# work phone# CURRENT MAILING ADDRESS: �` ®� MIA city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is,or is intended to be,a one or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. I� Signature o eowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\homeexempt.DOC Op SHE rpm Town of Barnstable Regulatory Services SARNSM1f ` MASS. Thomas F. Geiler,Director y nes. g. �'°TFo �aim Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 t Property Owner°Must Complete and Sign This Section If Using A Builder' A r 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 If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORMS:O WNERPERMISS ION i 2011-06-13 23:06 AMER ICAN*TENT*TABLE 5084202705 >> 508 790 6275 P 2/2 i Cerfifitate of iflame Resarslance REGMTERED ABTEC TENTS 0"14 or APPLICJolOq COWWRW no. 2M COLUMBIA ST `"a" TORRANCE,CA 90503 f 8 Ca.COUB r-4161of (SW)228-3097 This is to cer*dw the materials dWwi*W below hereof hvw bee»No, r�atarddant treated(or arse itfhrnerrtfj�rrorrltar►vrrebk�l. FOR AMERICAN T ENr dr TABLE 1NC. 301 OLD FALMOUTH ROAD UNIT 41 MARSTONS MILLS, MA 02NO CerUffcatlon Is hereby made that: (check "a"or "b'7 (a) The argcles described below this cerMicate how been treated with a flame retardant chemical approved and registwed by the Slate Firs Marshal and than the applioadonof said chemical was done in confor. mom with the laws of the state of Califomis and the Rules and Regulations of the State Fire Marshal. Name of ohemlc A used...........................................Chem.Reg.Me................._ .... Meathodof applkation..»................................._......................................................... (b) The arlicles described below,hereof are made from a!lame-repl9Wt fabric or material registered and approved be the State Fire Marsha)for such use;Fabdo has been tested and ansm o NFPA7014ML Trade name of flame-resistant fabric or material used.."mie0'0 ' .Reg.No. ....Ftllbtti...... .wLL.Nor.. Bo Removed b Washing The Flame Retardant ProGoss Used . ... y g (VA«WX�. David Bradley Chuck Miller- President " CUSTOMER ORDER NO, R169643 ITEMS MANUFACTURED: 2 3WO 2PC STD nos ULTRA WHrrE Arc STYLE CLASP 3 30XIo STD M/DLLE TOP ULTRA WHrrE ATC STYLE CLASP 2 ROW2PO�SMWP UL-TRA-1A HME Al1C STYLE-CLASP �r7S 2OXIO STD JWDDLE TOP ULTRA WHrrE ATC STYLE CLASP 215XJS 2PC ST p TOP ULTRA WW7V ATC STYLE CLASP f 16X10 STD MIDDLE TOP ULTRA WHITE ATC STYLE CLASP 1 15X I8 STD MIDDLE TOP ULTRA WHITE ATO STYLE CLASP ACORDL CERTIFICATE OF LIABILITY INSURANCE TIB:CERTFAAME E ISSM AS A MATTER OF•FORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE NGLDERL TM CERTFICATE DOES NOT AFmmTNELT7DR NEGAT meLY MEND,EXTEND OR ALTER THE COYENRAGE AFFORDED B1f TIE POLICES BELOW TM5 CERIFTCATE OF DMRANIE DOES NOT OONKMWE A CONTRACT DEITdEB/THE aSUNG W=Wd RM MnllORfZED WIM9fTAlMVE OR PRODUCE AM IM CO FWATE NOLDBL OWORTAM.B the holder M ss the PmICm nLwt be endorsed.E StIBROTaATiON E TMAN�,stOjeet tL► the tams and oondifoEL-of the poft"oeA�iEL p �oiaies Rle- e an a donsernmLl A state�rrerrt On 11riM o�ieate does not oorLler rit�Lls b the oer66cate holds in fieLr d such sELdorsement(s} Ntootrcee '. 1ISI Rental Speebifts 8o0 mi-i 6 P.O.Box smo AM bvkw,CA SM9 oLr 900854-3290 AFsarsraoo E rurL:s ■sue =WRERA:St Paul Fine A MN_ h uranoe Anudeml Tent A Table Ina LrMurtsL s:Phoenix kn ranoe ComPwV P O Box 1349 mac: MaTstans MBIs,YA 0260 .rsuLeLo: msu�E: . asLrAr3rF: COVERAM CERTFTCI►TE NUXNBER REVISION Numom THS G TO CERTIFY THAT THE POUCES OF NS41RANCE LISTED BELOW HAVE BEEN MMM TO THE MMM NAMED� TO UCY POOM TLtIS MO"T®.Nor*n STNOMK'ANY FNMF IMWV.TERM OR COMnON OF ANY CONTRACT OR Un*R DOAAE1r1 CERiIF1G►M MAYBE ISSM OR MAY MWAXl TIE pMM3ANCE AFFORDED BY THE POUCE8 D t�E SUBJECT TO ALLTHE TERMS. EECLUMM AND COIOt WW OF SUCH POUCOS.tM ITS SHOWN MAY HAVE OEM Remcm BYCIJLIW^- t33 � �R TM OF ONURANOE Pau"Awn wn A 4093MUABLM 21�Dt1O121H'AOt r�LcrrOoaw E Frtersas eedn.e s1S 90 CL4*r UWE C9 cc" pe N$ONALL MWWAW st AM GE NEPAL.AGM&S� loo pamum.compw L9G $1 GBrt.AGQV;GA7 UWfPPPUE5VM s X Foucr coso�srl6LEUR s � AuroEEosnEucearrr i Esao6e�0 AWARO BOOLYNA/rY O s ALLOWNWAriOB B00s-YILRRK 4 i 9pIE301AMAUTOFrE s �raoeiawA HIRED ArtO,S s ►rorLOMED A M Fes+ s tRa13"UAs OOCML s EXeeacws CLANr64MM s cE s s 4MA X woto70�I1186819Mg7511 AEoejj6,A3 UAatm► •/N F1.EFACHAMYPnDEtl N ELOISEILSE-FJ► it mm DOC�uOEE? 1LwJ1 i El_=SEA_=-PGlGYL1/T * °�`"°°of H31RO11 O rzum l $ Ao Lifflit :A EgLiVnm t Fioatter � � Form pZAsscti�AbiwewaPLs'sre1wel valmlim0FOPOUM sILOCATM i/v�ti�L.sAooRoN+.AeLtiLo.+ This owror,ate is issued go a/naW Of I °f*• ;i cAucaiwTwN TE _ oe tea IpEs BE CANCBJ�OEFM WITA Ej POVWF,PRd'IS� oE3Jr61�M ACC0lRDANDE . AurrroRoeo aEsaeseR� ` fT�•� 0t�9es-?A09 A� Tom'A9 EiAdRs reserved. 1 d 1 Tf Le ACO� and logo see n— °f ACONiD CXA.IG 9orlak264603 The Town of Barnstable Department of Health Safety and Environmental Services- Building Division 367-main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building'Commissioner Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. _ /Type of Work: Estimated Cost Address of Work: Owner's Name: c/ Date of Application: `' 92 I hereby certify that: Registration is not required for the following reason(s): Work excluded by law C]Job Under$1,000 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 WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner. Date Contractor Name Registration No. OR 0 • Date wner's e q:fomu:Affidav f SOLID figLUMBER,INC. ® Stronger Floors. Straighter Ceilings. Boston Metro (800) 843-9663 CT Metro (800) 832-8089 Wilmington, North Carolina (910) 762-9878 ■ (800)999-9105 Atlanta Metro (800) 241-9089 Femley, Nevada (702)575-5700 ■ (800) 223-5647 LPI Joists ■ Gang-Lain LVL ■ Inner-Seal Rim Board ■ Wood-E Software �i 2_ y �,o t i 3G4 ' I I Z�10 i F/e ' ell X ! i ' I /G, i I JOB NAME: JOB # LOCATION; SHEET OF SALESMAN: BY DATE Primed in USA. i TLUMBER,INC.fig o Stronger Floors. Straighter Ceilings. Boston Metro (800) 8 9663 CT Metro (800) 832-32-80898089 Wilmington, North Carolina (910) 762-9878 ■ (800)999-9105 Atlanta Metro (800) 241-9089 Femley, Nevada (702)575-5700 ■ (800)223-5647 LPI Joists ■ Gang-Loan LVL ■ Inner-Seal Rini Board ■ Wood-E Software zXtz12��(ge x �{ -yueK / i cr 7T i JOB NAME: JOB # LOCATION: SHEET OF SALESMAN: BY DATE Printed in USA. f SOIL D START SiO LUMBER,INC. ® Stronger Floors. Straighter Ceilings. Boston Metro (800) 843-9663 CT Metro (800) 832-8089 Wilmington, North Carolina (910) 762-9878 ■ (800)999-9105 Atlanta Metro (800) 241-9089 Femley, Nevada (702)575-5700 ■ (800)223-5647 ' LPI Joists v Gang-Lan LVL ■ Inner-Seal Rim Board ■ Wood-E Software 2X 12_/r2`(G -C 17 I �O(T5 2.X lC, 2X.. 12 JOB NAME; JOB # LOCATION: SHEET OF SALESMAN: BY DATE Printed in USA. ® START O*LUMBERIINC.SOLID ® Stronger Floors. Straighter Ceilings. Boston Metro (800) 8 CT Metro (800) 832-32-8088089 Wilmington, North Carolina (910)762-9878 w (800)999-9105 Atlanta Metro (800) 241-9089 Femley, Nevada (702)575-5700 ■ (800)223-5647 LPI Joists ■ Gang-Loan LVL ■ Inner-Seal Rim Board ■ Wood-E Software �r aLPU,GD• (O� roe j�3� j r2os7 U C( Gf C4LA11-11y, c(i --c Px(St cj-( JOB NAME: JOB # LOCATION: SHEET OF SALESMAN: BY DATE Printed in USA. i i i M QNR AppwAjx Table JLL1b(eondoo d) _ pr esiptive Packages for Oae and Two-Family Residential Boiidinp Seated witb Fossil Fuels MAXIMUM MINIMUM Glazing Glazing Ceiling Wall Floor I Basement Slab Heating/C001ing Ate'('A) U-value= R-value R value' R value' Wall t'rritneter Equipment Efficiency' pie R value` R value' 5701 to 6500 Headog Degree Dare' Q 12% 0.40 38 13 19 1 t0 6 Normal R 12% 0.52 30 19 19 10 6 NomW S 12% 0.50 38 13 19 10 6 85 AFUE T IS% 036 38 13 25 N/A N/A Normal 15% 0.46 38 19 19, 10 6 Normal 15-/0 0.44 38 13 25', N/A NIA 85 AFUE 157e 0.52 30 19 19 10 6 SS AFUE tAA 19% 032 38 13 25, N/A N/A Normal 19% 0.42 38 19 25 N/A N/A Normal 18% 0.42 38 13 19 10 6 90 AFUE 19% 6-50 30 19 19 10 6 90 AFUE 1. ADDRESS OF PROPERTY: -2. SQUARE FOOTAGE OF ALL EXTERIOR WALLS: 3. SQUARE FOOTAGE OF ALL GLAZING: 4. %GLAZING AREA(#3 DIVIDED BY#2): 5. SELECT PACKAGE(Q—AA-see chart above): \ NOTE: OTHER MORE INVOLVED METHODS OF DETERMINING ENERGY REQUIREMENTS j ARE AVAILABLE. ASK US FOR THIS INFORMATION. BUILDING INSPECTOR APPR . YES: NO: q-fomns-f980303a 780 CMR Appendix J 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%of the total glazing area may be excluded from the U-value requirement. For example,3 ft of decorative glass may be excluded from a building design with 300 W of glazing area. 2 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 J1.5.3a. 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 construction. If the insulation achieves the full insulation thickness over the exterior walls without compression, R-30 insulation may be substituted for R-38 insulation and R-38 insulation may be substituted for R49 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 plus 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 floor requirements apply to floors over unconditioned spaces(such as unconditioned crawlspaces,basements, or garages).Floors over outside air must meet the ceiling requirements. `The entire opaque portion of any individual basement wall with an average depth less than 50%below grade must meet the same R-value requirement as above-grade walls. Windows and sliding glass doors of conditioned basements must be included with the other glazing. Basement doors must meet the door U-value requirement described in Note b. 'The R-value requirements are for unheated slabs.Add an additional R-2 for heated slabs. ' If the building utilizes electric resistance heating use compliance approach 3, 4, or 5. 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)Glazing 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 0.35. 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 J1.5.3b. 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 0.35). 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 area-weighted average U- value of all windows or doors is less than or equal to the U-value requirement(0.35 for doors). 43 I I _ --_- - The Commonwealth of Massachusetts Department of Industrial Accidents id ..... Office ofintrestigations 600 Washington Street Boston Mass. 02111 Workers' Compensation Insurance Affidavit /%%�:..-..: name: location: kz� city phone —3-7 J ffi I am a homeowner performing all work myself. ❑ I am a sole proprietor and have no one workin in any ca acity ❑ I am an employer providing workers' compensation for my employees working on this job. company name address: city: phone#: insurance co. R01icV# ❑ I am a sole proprietor, general contractor, or homeowner(circle one)and have hired the contractors listed below who have the folloning workers' compensation polices: . .......... • company name: - ::::::.:::::..... . address: city: phone#• ....:....... ...::.:.:. /. :..:...:.. ...... .. ..::..:.. .:..... N.- company name: ........ address: city. phone :.. insurance co. olicv# . <::>:«<?:> Fallure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a tine up to S1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a tine of 3100.00 a day against me. I understand that a copy of this statement may be forwarded to the OMce of Investigations of the DIA for coverage verification. I do hereby certify under the pains and penalty rjury that the information provided above is tru,-and correct Signature . \ry\- 4� . --— -Date 1 9 _ Print name oI " Phone N official use only do not write in this area to be completed by city or town official city or town: permit/license# ❑Building Department ❑Licensing Board ❑check if immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone#; _ ❑Other (tevaea 9/95 P1A) Information and Instructions -- Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", an employee is defined as every person in the service of another under any co=-- , of hire, express or implied, oral or written. �j 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 receive.c: 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 groundsl,or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewa.i 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,, 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 in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of insurance as all affidavits 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. City or Towns 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. The affidavits may be returned io the Department by mail or FAX unless other arrangements have been made. i The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a call. The Department's address,telephone and fax number: '1 The Commonwealth Of'Ma'ssachtisetts Department of Industrial Accidents Me of Inllesflgadons j 600 Washington Street Boston; Ma. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 eat 406, 409 or 375 SOLIDSTART' OikLUMBERIINC. ® Stronger Floors. Straighter Ceilings. Boston Metro (800) 843-9663 CT Metro (800) 832-8089 Wilmington, North Carolina (910) 762-9878 ■ (800)999-9105 Atlanta Metro (800) 241-9089 Fernley, Nevada (702)575-5700 ■ (800) 223-5647 LPI Joists ■ Gang-Lean LVL ■ Inner-Seal Rim Board ■ Wood-E Software 3�G.e i JOB NAME: JOB # LOCATION: SHEET OF SALESMAN: BY DATE ?nrned in USA. IP! SOS D START ,�I _AN LUMBER,INC. t��Stronger Floors. Straighter Ceilings. Boston Metro (800) 843-9663 CT Metro (800) 832-8089 Wilmington, North Carolina (910)762-9878 • (800)999-9105 Atlanta Metro (800) 241-9089 Femley, Nevada (702)575-5700 • (800) 223-5647 LPI Joists ■ Gang-Lan LVL ■ Inner-Seal Rim Board ■ Wood-E Software f:ie rook — — — — 2- 1 - —.--- _...--- �3,cK C�lc 6s� t 21 Cf C6-f112Y p(k --C exl5rtQ_9, �Gj)k_g1 G �_DD_* JOB NAME: JOB ## LOCATION: SHEET OF SALESMAN: BY DATE Printed in USA. SOLID STARTry �U _AN LUMBER,INC. ® Stronger Floors. Straighter Ceilings. Boston Metro (800) 843-9663 CT Metro (800) 832-8089 Wilmington, North Carolina (910)762-9878 ■ (800)999-9105 Atlanta Metro (800) 241-9089 Fernley, Nevada (702)575-5700 ■ (800) 223-5647 LPI Joists ■ Gang-Lean LVL ■ Inner-Seal Rim Board ■ Wood-E Software 2x )2_1jz`(0 -C 2Xg5 of 5r-� 2X16) 2x12 5 z r s�CC set 2� r /�% JOB NAME: JOB # LOCATION: SHEET OF SALESMAN: BY DATE Printed in USA. - SOLLD STAR7 fiikLUMBERfINC. o Stronger Floors. Straighter Ceilings. Boston Metro (800) 8 CT Metro (800) 832-32-8088089 Wilmington, North Carolina (910) 762-9878 ■ (800)999-9105 Atlanta Metro (800) 241-9089 Femley, Nevada (702)575-5700 ■ (800) 223-5647 LPI Joists ■ Gang-Lam LVL ■ Inner-Seal Rim Board ■ Wood-E Software 4' yveK I z a Cv�GS S - 3g,: -cc i/,gC JOB NAME: JOB # LOCATION: SHEET OF SALESMAN: BY DATE Printed m USA.. t Application to Old Kings Highway Regional Historic District Committee in the Town of Barnstable for a j. 9 9 9 02.9 CERTIFICATE OF APPROPRIATENESS Application is hereby made, iri triplicate, for the issuance of a Certificate bf Appropriateness under Section 6 of Chapter 470. Acts and Resolves of Massachusetts, 1973. for proposed work as described below and on plans, drawings or photographs accompanying this application for: CHECK CATEGORIES THAT APPLY: 1. Exterior Building Construction: ❑ New Building JN Addition ❑ Alteration Indicate type of building: ❑ House ❑ Garage ❑ Commercial ❑ Other 2 -Exterior Painting: 3 Signs or Billboards: ❑ New sign ❑ Existing sign ❑ Repainting existing sign 4. Structure: ❑ Fence ❑ Wall ❑ Flagpole ❑ Other (Please read other side for explanation and requirements). TYPE OR PRINT LEGIBLY DATE _ V ADDRESS OF PROPOSED WORK a 7 Ic Lu/e4 T WL ASSESSORS MAP NO. OWNER 21C4" Ayo P�R(C1A ASSESSORS LOT NO. HOME ADDRESS S "w►P TEL NO. S, 2-37?� . . FULL NAMES AND ADDRESSES OF ABUTTFNG OWNERS. Include name.of adjacent property owners 46oss and public street or way. (Attach additional sheet if necessary). �' � _.. AGENT OR CONTRACTOR !U TEL NO. ADDRESS DETAILED DESCRIPTION OF PROPOSED WORK: Give all particulars of work to be done(see No.8,other side),including materials to be used, if specifications do not accompany plans. In the case of signs,give locations of existing signs and proposed locations of new signs. (Attach additional sheet, if necessary). AVP`Ctt dtv - Sew �T.4 � b U Signed \^ 4L Owner-Contractor-Agent Space below line for Committee use. Received by H.D.C. Date`` '' -The Certificate is hereby Date Approved ❑ IMP TANT: If Certificate Is approved,approval Is subject to the 10 day appeal period provided in the Act. n _ KALWEIT 300 F.T.ABUTTERS LIST MAP# PARCEL# PAR.EXT LOCATION OWNER COOWNER STREET CITY STATE ZIP MAPPAR 111 ' 8 1 85 W MAIN ST SILVERMAN IRA F TRS 1997 1 F SILVERMAN FUNDING 79 MARBLE R_D_ BARNSTABLE MA 02630 111008001 e 111 9 49 LISA LANE WB PIERCE REBECCA A 50 LISA LANE W BARNSTABLE MA 02668 111009 ✓ At 111 10 27 KALWEIT DR W BARN KALWEIT DOUGLAS M& KALWEIT PATRICIA A 27 HOWLAND LANE W BARNSTABLE MA 02668 111010 ✓ a 111 11 1 52 HOWLAND LANE WB BRYSON ROBERT E&LYNDA A 52 HOWLAND LANE W BARNSTABLE MA 02668 111011001 ✓ a 111 11 3 OFF KALWEIT DR W BARNS KALWEIT HILDA F P 0 BOX 461 W BARNSTABLE MA 02668 111011003 ✓ 111 20 48 SCORTON HILL RD WB KEARNEY RICHARD&MARGARET 48 SCORTON HILL ROAD W BARNSTABLE MA 02668 111020 ✓ �. 111 21 30 SCORTON HILL RD BEILMAN EDWARD J BEILMAN EDWINA N 30 SCORTON HILL RD W BARNSTABLE MA 02668 111021 ✓ 111 22 10 SCORTON HILL RD W B BECKER S ALAN TRS SCORTON HILL REALTY TRUSI 10 SCORTON HILL RD W BARNSTABLE MA 02668 111022 ✓ 111 37 88 WILLIAMS PATH ROAF DONALD RJR& ROAF KIMBERLY S 88 WILLIAMS PATH W BARNSTABLE MA 02668 111037 ✓ 111 41 OFF HOWLAND LANE BURGUND JAMES W&MARCIA 20 HOWLND LANE E SANDWICH MA 02537 111041 ✓ 112 1 HOWLAND LANE WB BELFIT THEODORE C BOX 301 W BARNSTABLE MA 02668 112001 112 4 39 RTE 6A ONEIL FRANCIS P 39 MAIN ST W BARNSTABLE MA 02668 112004 (� 111 11 4 55 LISA LANE W BARN HITCHCOCK THEODORE& ' HITCHCOCK KATHLEEN P 0 BOX 654 HYANNISPORT MA 02647 111011004 ✓ 111 11 5 169 LISA LANE W BARN IMERRITT KEVIN S P 0 BOX 1955 COTUIT MA 02635 111011005 O 111 5 1 125 PAANANEN CIRCLE JPAANANEN MARY MAIN ST W BARNSTABLE MA 02668 111005 001 ✓ rk ' Page 1 :. ... .. i i Property Location: 69 LISA LANE W BARN MAP ID: 111/ 011/ 005// Other ID: Bldg#: 1 Card 1 of 1 Print Date:01/26/1999 ::..,.1rc'i .',�,. F,._..._ ... ' .. ..'` .., ,CURRENTO.WNER� :lUIILI�7lES� STRaT1ROAD_ EOCA}fiION w,M51,_ ��.�,�.>� ._ ,. a_,._. ERRITT,KEVIN S Description Code I ADvraised Value Assessed Value ES LAND 1010 65,500 65,506 801 9 LISA LN RESIDNTL 1010 175,800 175,80 BARNSTABLE,MA 02668 A U,F'PL^ r ,70 SIDNTL 1010 20 2070 BARNSTABLE,MA EIIaEN,TAL�D�1T.4�?:�� �li��+� �: ccount# 353888 Plan Ref. ax Dist. 500 Land Ct# er.Prop. #SR Life Estate VISION DL I LOT 3 Notes: �- - - DL 2 Tota4 62,00 262,00 RRITT,KEVIN S 9449/318 11/15/94 U V 75,00 N Yr. Codel Assessed Value Yr. Code Assessed Value Yr. Code Assessed Value HITCHCOCK,THEODORE&KATHLEE 9348/205 9/15/94 U V. 92,00 F ITCHCOCK,THEODORE& 8828/344 10/15/93 U V 92,00 N IDA,DANIEL J 2428/196 U D Total. 67 80 Total. 59,7001 Total. 59,700 -'-i..x.�&"' F : arc,ir r �x-+a+t` `?- .:2`"'?f :-u,.G,..Xx�' Sys•. -P"'i �';.h zsr'}.",t. xh. ,;a, _ * 'r° , :% XEMPT1ONSmt , r ` OTHERASSEtSS1G1NTSx x This signature acknowledges a visit by a Data Collector or Assessor Year TvvelDescription Amount Code I Description Number Amount Comm.In AISEDf„YA UES MMARY R_ Appraised Bldg.Value(Card) 172,200 Appraised XF(B)Value(Bldg) 3,600 Total. _ Appraised OB(L)Value(Bldg) 20,700 APPraised Land Value(Bldg) 5+5 00 Special Land Value 0 S "FOUND ONLY 1/96 P ................ } _.. _ .. . Total Appraised Card Value 262,000 _r_.._. . Total Appraised Parcel Value Valuation Method: Cost/Market Valuation Net Total Appraised Parcel Value 'x � - -... ._:: _ r._K � .,.. ;.:� .:...,�. �h. ...... M,�:,. ,�.�m x.._.d:. :a� �• ,,,. a.s, .. � ,.. .. �' + � .. +:"��s �'.w �"s.'�r,:*=:_., .z°:`.r.MF,�.� .<�...J` s :,. .� �_..B,UILDINGP..ERMl�'RECORb, . .�,:, ak>xi,�;.s�=:_f...,_._�.._...:.,�. ..=-" .�_ _>a,_...> � . ._ _. . _ _ _.._ _ ...:�,,__..��,; -. _ ...�- - _�: -_,�.,K,_ �,;�_�.._.:. �- �. �[/IcSIT/CHANGE`HISTORY.: Permit ID Issue Date Tvpe Description Amount Insp.Date %Comp. Date Comp. Comments Date ID Cd. Purpose/Result 9486 8/1/95 ND 150,00 111/97 , 90 WB2STOR ..u'.a v.., .._- r,._. .,, ..a-.v�:�rc N:1i:tic. ..:: •^y-ti--�sce�_- o ..__ s_r. .... _,a,x,s_»_.a�.:., -:F.•":. _._ _...,,r ,n ..'l. :..:'! 1 ,._.;a_, .,:a. ,,.s_. .:ry:....,..,. s. :,a a� ,a. aF 1 ..,.,W.::> _s..- ,,>��.�.�,,",.� �,�,.,�;� •_,.r.,, .K.,.���, ,,_:._....�. ,�:��,�. _ ._: .. � __.. . ,.y. ., __.�.,. i,ANb:�INE VAT�iTATtON�:SBCTION�,��,�„ z-,:�.. ���.., '�'„ . �,>,, 1�k C....k ,.� "'N.�..�n' .., _,.. .,_ a.,. _.�>:.,._a:e: �s.. �s, _z_. .1wx�` .,,r B#I Use Code Description Zone D Fronta a Depth Units Unit Price I.Factor S.I. C.Factor I Nbad. Ad'. I Notes-Ad YS ecial Pricing Adj. Unit Price Land Value 1 1010 Single Fam RF 5 1 1.00 AC 100,000.09 1.00 5 1.00 87AB 0.5510 1BLDG.SIT 55,000.0 55,00 1 1010 Single Fam RF 5 1 0.90 AC 21,200.0 '. 1.00 5 1.00 87AB 0.5511 IRESIDUAL 11,660.00 10,50 I Total Land Unl 1.9 A Total Land Valu 65,50 Property Location: 69 LISA LANE W BARN MAP ID: 111/ 011/ '005//, Other LD: Bldg#: 1 Card 1 of 1 Print Date:01/26/1999 F" - VIM z.: -F•�u5.,b'".fi:ai 2:::c�..-.. .....:.rr.m:-+r :. .x.:<.. :.:,. .. .a. 2 .P� .x._ ,. ....:.e.<.x. :..:,t_,.:t ,:;:.y r.. ,... s!.�.._ ... ,.-e.. - _-, ._ ly`..... x.. ,,, i,.. ..: ,.... a ,x�x ,..--a—�: ,.�.:<+:� �: Tt1!'L N r..,..a t_ �x... ��.� � - .�,:.:. _.._..__Yk...-�'i�`+L..�.�xr.-SMn�kF.,�Tk?k^!„ ;..F...S1-a;..,��z... � =��<�:C!�i'� �. Element Cd. Ch. Description Commercial Data Elements ty1d Type cololligi Element Cd. Ch. Description odel 1 Residential icat&&AC 20 ade Tame Type aths/Plumbing 14 tones 2 Stories 14 ccupancy 1 CeilingfWall WDK ooms/Prtns 6 P W& xterior Wall 1 4 ood Shingle /o Common Wall 20 502 2 Wall Height oof Structure 3 able/Hip _ ' - " CONDO/COOPDi9TA oof Cover 3 ph/F Gls/Cmp k�;� �_� ._.�£�.n- _R..x,. �.r.--��. ��.�,r=x�:=-� 14 Element Code Description Facltbr 16 16 Interior Wall 1 3 Plastered Complex 2 Floor Adj BAS Interior Floor 1 2 lardwood Unit Location 4 7 UBM 7 2 4 arpet umber of Units BAS FUS g UBM eating Fuel 3 as 4umber of Levels eating Type 5 lot Water /o Ownership 7 C Type 1 one ; COST/M4`R1fCET f!f1LU�1TIOL9 8 8 nadj.Base Rate 8.00 0 25 edrooms 3 3 Bedrooms ize Adj.Factor 94692 athrooms .5 3 1/2 Bathrms ade(Q)Index 37 7 otal Rooms 1 Rooms dj.Base Rate 2.27 20 Idg.Value New 73,920car Built 996 FOP Bath Type 2 Modern ff.Year Built 996 34 Kitchen Style 2 Modern rml Physcl Dep uncnI Obslnc 3" *161IXED_°USE t Nate' ; conObslnc pecl.Cond.Code 1010 Single Fam 100 ipecl Cond% erall%Cond. 99 eprec.Bldg Value 172,200 Code Description LB Units Unit Price Yr. Dv Rt %Cnd Apr. Value. FGR7 Gar w/Lft Good L .648 32.00 1997 1 100 20,70 FPL3 Fireplace 2Sty B 1 3,600.00 1996 1 100 3,60 x" BCI1lDING�S IB AnEa�S0 RRA RM rjS.96rzoN Code I Description Livin Area Gross Area E .Area Unit Cost Unde ree. Value' BAS First Floor 1,241 1,248 1,24 62x2 17,71 FOP Porch,Open,Finished 43 8 12.4 5,41 FUS Upper Story,Finished 1,16 1,160 1,160 62.27 72,23 UBM Basement,Unfinished 1,216 243 12.44 15,13 WDK Wood Deck 552 '55 6.20 3,42 i 240 461 279 +-17392 Property Location: 85 MAIN ST W BARN MAP ID: 111/ 008/ -..001/./1- Other ID: Bldg#: 1 Card 1 of 1 Print Date:01/26/1999 ILVERMAN,IRA F TR Description Code ApPraised Value Assessed Value Y.SILVERMAN,IRA F&CAROL L RESLAND 1010 41,600 41,600 801 5 MAIN ST RESIDNTL 1010 77,800 77,800BARNSTABLE,MA BARNSTABLE MA 02668 ,, �, - o' o ccount# 54069 Plan Ref. 245/78 Tax Dist. 500 Land Ct# er.Prop. #SR VISION Life Estate DL I LOT 1 Notes: DL 2 Tota4 119,40q 119,40 : -,ss ..,mom.-...-max. .. ,:. ., - „,- .:. ,. ,. .,,a.-. ::.:,,-c>::- _ a;,-.au.:x-•,.n _ - A �{� :'?'>5-'.,, Yrl ...._ '�:•'=....,_ , :. , :...,,. , ...T:j;�rY`�,xTq.'J^._,a 1, : i x.K3 ?( ,E _ .: J i i i.1 ,. Fh: 6:k�',h.�-'S.Ra,!54 -t'�� � >t C..a_'?Y .Y�Aa ,ua?.,. . + �i 1 : ': ., � ( _. ,zi J �:-� _3.. : 9 � v. !i}" _. h I�� .`._� Ya,�•i �,X :�':! T,�,._�'...xa. a:���?. ,�,�>iPRE,�ZU;USr,41-.SSESS1VlEN_TS'HISTOR�� ILVERMAN IRA F TR 10863/339 7/23/9 Q I 170,500 00 Yr. Codel Assessed Value Yr. I Code I Assessed Value Yr. Code Assessed Value IIVCHESTER,PETER F&CHRISTINE H 2852/22 Q Q VERMAN,IRA F&CAROL L 11473/130 6/2/98 U I 1 IA To afj 131,000, Total. 131,000 Total. 13100 ..wr,v.'.��..,� fiX'�."li - W1.16 „I .,!G". c F,�`:.. �,, " �..t . ��:±In'�.M'Tay:. t � � �E,yLMP' O,N.S,,; ��� ;'��� ��; �� ��.�;�.�' '�,��'�����-'� �09"HL�1t;�ffSSESSMEIVTS�wa.�,r �„'�:��"��x��a�-sa:� This signature acknowledges a visit by a Data Collector or Assessor Year TvDelDescription Amount Code Description Number Amount Comm.Int. T�ALUESUM�YfARI'Oil s1 k 1 r Appraised Bldg.Value(Card) 75,300 Appraised XF(B)Value(Bldg) 2,500 Total. '�._L.s:,a�.�.��'�h_c_�wr_k_�r�.r��?.:..,;+,K_;..m".:.�.�x�;xn-�,.���,,fi,,,..5 1.,,.�.,.��..,..,.x.w S-��..:�i_h.s.a��+:..°:�c,^"'�.&.6adr�.�.6,'��a:.+�4"�._,�,aw:.R..,a�,,..'�r.:M"I.,n�.�.,'-�_.am�:_p..,�F-.�x!N..d,:T,ES�,�R.,.�._n�::...,z:k-.:�te�a.1'a�.�._h?..."v._,;..5:.��x�>;.'.�....�:_��.F.,:tt,,-�,�.xF,:._,.:.:...�:a._,,,a,.:��.:.;l,.,'.�¢"�^'..a-r_c,��,.w.-,'a,.m,.+�:�.�...._Y..}�:�..:.:..i,C.:u:Y...�ux.....:..n->-x+�.a.•.,�."���. _;s�x;.,�N.��_r"�.1 Appraised raised Land Value(Bldg) g)� _ *LAND ADJ VIEW.. Special Land Value 0 _Total-Appraised-Card-Value— -- — - —1-1-9,400. _ Total Appraised Parcel Value Valuation Method: Cost/Market Valuation Net Total Appraised Parcel Value .z:-;.;._.a.a.,:. i a .z. .xf, _:F:..,,a._:.n -." b.a.val r .a .. .,... • . - , rl{ ._.x.z4.. .,;y, t.,a.�.+F .-.,,,a,..�. '.,,.. y_xm�,•,:.., ti i.-xc�2'a s �.„.:.,...:.,s - Permit ID Issue Date T e Description Amount 1 ..Date %Comp. Date Coma Comments Date ID Cd Pu ose/Result ttut-,.:. „�. ,-� �-,,,..,,,�.,�,:,.,�:. �I�tl:-��+,3�a T .a--�>�,� -a,..�,- -�,,,: .,:v.,�<� _ ,>, .. =. . .. < ,....• ,.� .1;' -�: x 1 as ?- _:�a—.. B# Use Code Description Zone D lFrontaize Depth I Units I Unit Price L.Factor S.I. C.Factor Nbad. Ad Notes-AdYS ecial Pricin Ad Unit Price Land Value 1 1010 Single Fain RF 5 1 0.80 AC 113,000.00 1.00 5 1.15 88AB 0.40 10 1BLDG.SIT 51,980.00 41,60 Total Land Unt 0.8 A Total Land Valu 41,60 Property Location: 85 MAIN ST W BARN MAP ID: 111/ 008/. 001// Other ID: Bldg#. 1 Card 1 of 1 Print Date:01/26/1999 _. T.Ta r•'x=aat�r'i�;x;.: . —_•�k- .,w.,,a ,..,.e i ,.. r ._.. .. ... K fiver.x;a:� ,*a::. :, - XVAM.�,tT'_... .'i."j., .....:'k > ..kv.n^R....s4n:.__E .. :. .. r :*'.`�_�_..... ^'a-..ij. _ .• A••-..-W .23: _ t Si^....., :� H ':.use.,-_ .{ T..M. ._ . :P .. � r . "�. ,.6-�h..��=..-a. .a _ .'�L...,, 'k T51 L Y. Si• .a'. ,:ca_.. ��IT f � I .F i.._:•���.... .. ��, �••.cM . _ �, __:�. .. N.S.TR.IfiC7"ION�DE•TAi`� �. .. .. � �•a 4 , .. .,�...« '.. .:. ��r � w;,., ':�. ,. ,._ ,� ,..� .. . Element Cd. Ch. Description Commercial Data Elements Lyle/TYPRC 3 01001e1 Element Cd Ch. Description odel 1 lesidential 4eat&&AC 3rade C rame Type FUS[768] aths/Plumbing tones Stories - FUS[64] ccupancy 0 eiling/Wall ooms/Prtns 15 xterior Wall 1 4 ood Shingle /o Common Wall 2 Wall Height 10 PTO 0 oof Structure 3 able/Hip 5COND01C0 OI'DAkTA` F, fi t Rxr { Roof Cover 3 sph/F GIs/Cmp lement Code Description Factor 2015 3 32 Interior Wall 1 2 Wall Brd/Wood omplex BAS 2 Ioor Adj 2 UBM 2 Interior Floor 1 2 ardwood Jnit Location .2 BAS umber of Units 23 24 UBM 24 eating Fuel 4 Electric 4umber of Levels Heating Type 9 Typical /o Ownership' C Type 1 None * `: MICMT/M.411`ICET YALIUAMON 12 nadj.Base Rate 8.00 Bedrooms 4 Bedrooms ., .• 0 FGR ize Adj.Factor .99123 Bathrooms .5 1/2 Bathrms ade(Q)Index .89 _ 12 32 1 I Full+1/2 dj.Base Rate 2.35 }:. FOP Total Rooms Rooms ldg.Value New 6,558 ath Type ear Built 965 23 12 Kitchen Style ff.Year Built 975 r W Physcl Dep 2 uncnl Obslnc _7 £ �b3MIXEDJSEtF s e con Obslnc pecl.Cond.Code 1010 Single Fam 100 5pecl Cond% erall%Cond. 78 eprec.Bldg Value 75,300 0El Oi72`BUILDINGS&& YARDITMS{L)%XF BilIDGsEX7"RFFk41#URES{B) Code Descri lion LB I Units Unit Price Yr. I DP Rt °V.Cnd I Apr Value FPL2 irepl-1/2 Sty B 1 3,200.00 1975 1 100 2,50 :.0�r�-�'��'_,.z��'� �+: U�DI1VG.S,UB.AREA��SIl1V1hI,9RY�`SECTION:.�;��,� �"a���� '� ��^�,.� � •. Code I Description Living Area I Gross Area I Area Unit Cost I Unde sec. Value < BAS First Floor 1,0 1,044 1,044 423 44,21 FGR Attached Garage 46 161 14.8 .6,81 FOP Porch,Open,Finished 9 1 8.3 80 FUS Upper Story,Finished 83 83 83 423 35,23 PTO Patio. 15 1 4. 63 UBM Basement,Unfinished 1,04 20 8.4 8,85 1,87tj 3.620 2,56 96 5 Property Location: WEST MAIN ST W BARN AIAPID: : 112/ 002//% '``— Other ID: :' Bldg#: 1 Card 1 of 1 Print Date:01/26/1999 MIND— _ D�;src'�`;Yv�1T�;,.S^.'.xT'v:�a�.: •. ..�. .�.... .rE-._R .:Pi aTO .U-,�_T ... . . . �> ENr ELFIT,THEODORE C Description Code 1ADDraisedvalue Assessed Value BOX 301 S LAND 1320 20C 200 801 BARNSTABLE MA 02668. BARIVSTABLE MA , ' IIPPL� l>tIENTAL-:DATA ' ccount# 54489 Plan Ref. Tax Dist. 500 Land Ct# er.Prop. #SR VISION Life Estate DL 1 Notes: DL2 , 3 T0t4 20 20 HIP, �f!NERS- _ ELFIT,THEODORE C 6010/015 11/15/8 U V' A Yr. Code Assessed Value Yr. Code I Assessed Value Yr. I Code I Assessed Value ELFIT,THEODORE C 3541/143 8/15/82 Q _ I TO id 80 Total. 80 Total. 80 . a..-:.L�!a�: - �s,;x�>"» ,� :.�;. �`�..l.�E�1 >T r .�'''��,.xa k:,a;ax,"~�.�'F� �:_ —�—�^.=a =��c�g::=`,'rk��.„°>"'.��,,+�'.:k",,; r '�c,-• f .:..�'x,..y.'xr: <s.:�x -m�z�+�'�. �, � �.•::�s. -�.�:�` ___._�°�.TIO7yS��,� ---Year Type/Description Amount Code Description Number. Amount Comm.Int. Appraised Bldg.Value(Card) 0 Appraised XF(B)Value(Bldg) 0 Total. Appraised OB(L)Value(Bldg) 0 .=. .: ; a s a ,. Appraised Land Value(Bldg) 200 �.�.-�4_� --'�r-��, _ 'WERE�,� PP LAND ADJ FOR � � Special Land Value 0 SHAPE/WET --- --- -- `--Total-Appraised-Card-Value-- -�-- ----_-�- --200--- Total Appraised Parcel Value Valuation Method: Cost/Market Valuation Net Total Appraised Parcel Value x ;,;.m.�.,.s,• .z+- ,.._,.. .x�. ....... .:, - ... _ k....x__.T.s. x __ _.:....,._.....-aax.. ., <..�,. .e _ .. ..F7.x• 'i. u..�._..__�_,_._�__._-;�.��x:.a.....'_��;�.,,�mx.x�. . ,N>.�a�_�>,:,�., .._fir,_,_._�`-,�BClILDIKG P�RM1_'T�RECORD� ,,u-�.,,� a �..� �:,�.ka> ,L„751�/CHA1V6�.$ISTORY Permit ID Issue Date Tvve Description Amount Iris ?Date. %Comp. Date Comp. Comments Date ID Cd. Purpose/Result — t_ ,_.Y<K�zT:«.�:I 1,_.F' ..h.:._:—._-sib'•_ :a.,y.;.,.:�..a .:u?:;.Y�u z:ss,x. ... r«,. z _. Rnv. .. *,... —.F.�.z - : :x3.^s. ._.xF...v...Y, ,:.-<_.,v.x^.^":x.>T e.._... x.��z:^..z z% -,..SR..::b ,:�',::....f.... ^-c '::x• .aEx;c `�_ - ._ ', : ,., k B# Use Code I Description Zone D Frontage Depth Units I Unit Price I Factor S.1< C.Factor Nbad. Adj. I Notes AdYS ecial Pricinz Adi. Unit Price Land Value 1 1320 Undevable RF 5 1 0.61 AC 1,000.00 1.00 5 1.00 88AB 0.4 161WETLAND 400.00 20 t - TotalLandUnio 0.61 AC Total Land Valu201 Property Location: WEST MAIN ST W BARN _ MAP ID: 112/ 002//"/ Other ID: Bldg#: 1 Card 1 of 1 Print Date:01/26/1999 .r i � s r w, �..;i:. � r.��-1''.u.'^I.'L'u.,�.Lx: .!^T :.fit-�•'3..kS.r .� - - �.,'k'.-5'-. Si:^ K'S..--r. �L+-.>3 ,e .., o -.. ,.,c. �._«. .^.. - .,'l.. 'x z=x & .. :.:. 3 ,r...a r- .,.. _ .a,1 .,... -.. ts;f:-"—> ..^ .;,'�S-..:.- _x,::>-3• .C�oNs�x�C.�YO�!,DETaI�.�,�� - --_ .� � � �. ,� �� _,. .�__.____..._..___-;__._�__._--'--_�_,.._... a_ �-,-e'..:�".:�.ar:.,a � 'W�'. �.....:_.,.ks��� �.q;.,"� r,�;,t Element . Cd. Ch. Description Commercial Data Elements Lyle/Type 9 v2cant Land. Element Cd Ch. Description odel 0 Vacant ieat&&AC ade rame Type aths/Plumbing tories ccupancyCeiling/Wall ooms/Prtns xterior Wall 1 %Common Wall 2 Wall Height •oof Structure oof Cover a " CONIlO/CO OPD�T.1 *�.;, lement Code Description Factor tenor Wall I omplex 2 loor Adj terior Floor 1 Jnit Location 2 umber of Units Heating Fuel umber of Levels Heating Type /o Ownership C Type .. C_ 5.71KETVALU�T(ON�' edrooms nadj.Base Rate athrooms ize Adj.Factor ade(ty Index otal Rooms dj.Base Rate Idg.Value New ath Type ear Built itchen Style [prec. .Year.Built nl Physcl Dep ncnl Obslnc onObslnc MIR ecl.Cond.Code 1320 ndevable 100 ecl Cond% erall%Cond.Bldg Value OUTBUIlb7 NG&.& Y,4RD _ a , E )1S %. .() Code Description LIB Units Unit Price Yr. Dv Rt %Cnd I Apr. Value Niffir R �_ � � &B_,11�LDING?SX�B,%9RArC11V1I1fARYECT1'CIN #`" - . gg .,. " Code Description Livin Area Gross Area E .Area I Unit Cost Unde rec.Ydlue Town of Barnstable Old King's Highway Historic District Committee SPEC SHEET FOUNDATION SIDING TYPE �G(fie �D COLOR _ c CHIMNEY TYPE COLOR ROOF MATERIAL 3Tj _P /_ COLOR' /�►— �{?9(!�j(/ PITCH � � WINDOWS �f, COLOR SIZE TRIM COLOR DOORS !. x 6 COLORS SHUTTERS COLORS GUTTERS COLORS DECKS MATERIALS C GARAGE DOORS� COLORS SKYLIGHTS SIZE COLORS SIGNS COLORS P D n fl , �D� ��t � �4v u L FENCE COLOR NOTES: Fill out completely, including measurements and materials/colors to be used. Four copies of this form are required for submittal of an application, along with Four copies of the plot plan, landscape plan and elevation plans, when applicable. SPECSHT Revised 11198 r 4/ / Z3g 77 00 44.1 N ` 3 . O I _ hN N 4T. E I � I 89' I certify that this property is located in Flood Hazard Zone C (out- side the 500 year flood) as identified by the Department of Housing and Urban Development (HUD) . Date4ap_/4 C i?.fz CERTIFIED PLOT PLAN LOCATION .BA.P!!-S'TAGG �WG3r� jG6�y!r f. �yL SCALE . ./ DATE y. l�t C /99z Reg, band Surveyor PLAN REFERENCE I certify to its title insurance company that there are no visible encroachments (CERTIFY THAT THE E�RisT!.�G .D�!!�?-�!�✓G or easements except as shown and that this SHOWN ON THIS PLAN IS LOCATED ON THE GROUND plan was prepared under my immediate AS SHOWN HEREON AND THAT IT CONFORMS TO THE SETBACK REOUIREMENTS OF THE TOWN OF supervision. ;�A1Z!'!tSTj7.BGE WHEN CONSTRUCTED. DATE ez�; �o uct�s M. /.✓A c iN 6-7 r i7z,c.,A A• kAer •E4o.,-L�r 414, -AL AL -fr Alk- AL �c ! 4k— N11111 sk- 3V- / AL r i 1 AL NAp 41 DI ill,131 60 CD 43 Will }} V 5-2 }� 1 Iiia / Will ' �� ♦ •71- t DDPIII 40 MAP I I I PARCEL 10 DOUG KALWEIT W _ _E s SCALE: 111=200' RrOLAN .RSPti�4�t - • wh'it,� C8�7k� �( N►At� • 9 h�� PiYL"�� 3 rA6 ,�45Ph�Cr sk�vq'�S TIH ►� � "`7 w �R i a I . DDD o � 0 D eA f low yxrO ftLVq� cd�-7'��vcrrtG (Z-i��� VGA✓ tAR- P "Q, tPe- F4scc.4 u�ctk 3fflt3 e i ii voy3l� a____ S4 'lq V�vfS Cp�tGirJMaT `All(es / Z•x� stu�3 16"O•C Cv p�'2�� ce5 PLyecc-rj o � �rit�s i6`�O•c • sr-eleG S a w . �l1vy�Ls S133HS OOL b6l-LL o..dwd S133HS OO t Lb L•LL S133HS OS Lbl'LL V 1 v- <lr =oof9Al veep 1 - .SAU) -CUT-- I _ l3 RAC v+l.Fs�T cvi vR�1,P/ - peep eli15t'!411; i pveee- grAvu_ + 1 ej-��(CA)ce (N-( i w . d;9 S133HS OOL bOl-LL S133HS OOL Lbl-LL S133HS 05 101-LL Home � i �bd scolle f , f . S133HS OOZ Otil'ZZ ovawv S133HS OOl Zb l-ZZ S133HS OS lbl-ZZ e V` LsC �`c v-F 417 DLrt1��G tAj 8�,� Engineering Dept. (3rd floor) Map Parcel ermit# 10 ` .r4 House# GC"G�"� Date Issued l?/3ola& _Board of Health(3rd floor)(8:15 - 9:30/1:00-4:30) Fee ���•�'d Conservation Office(4th floor)(8:30- 9:30/1:00-2:00) Planning Dept.(1st floor/School Admin. Bldg.) 1HE Definitive Plan A 2Loved by Planning Board 19 ; RNSTABLE?` TOWN OF BARNSTABLE , Building Permit Application Project Street Address Village �' . k�C,c/2_�1 S4-69'E-Q—e `YYl-6 Owner } 4-- Address j Telephone Permit Request - First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ czo Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes ❑No On Old King's Highway ❑Yes ❑No Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: Existing New Half: Existing New No.of Bedrooms: Existing New vTotal Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size). ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use Builder Information Name I DQikltJ r S l Telephone Number i Address 71 �,�c-y-, (f/i2 License# / Home Improvement Contractor# _ //�S 3 6 Worker's Compensation#46 / NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO �!/1/CG�%%� SIGNATURE DATE /offD BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) FOR OFFICIAL USE ONLY PERMIT NO. Z V DATE ISSUED MAP/PARCEL NO. 7 ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION !!! FRAME " INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FILIAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. '7 °F The Town of Barnstable BAaNSTAs14 9� 116J9. ,0�' Department of Health Safety and Environmental Services AtEDMA'�A Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner For office use only Permit no. Date ' AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not; more than four dwelling units or to structures which are adjacent to such residence or building:be done by registered contractors, with certain exceptions,along with other requirements. -{ Type of Work: Est.Cost J 6 0-O Address of Work: �� pC /� �N-2.1`} i�iV� (�. C-)C vt l SJ�`i rJJ�-Q Owner's Name_ Ty S �2_ Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under$1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR 'DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. OR Date Owner's Name The Commonwealth of AhIssachusetts J _ -:- Department of Industrial Accidents Office Of/IIYeS1192t/ons '�\_s' ' :r �1 600 N aAhit rott Street Boston, Ma.v.v. 02111 �., Workers' Compensation Insurance Affidavit �►pplicant information: —^'Please PRINT lebibl�,� , name• locaition ?-7 l cite �W�7�/1 � Phone# I am a homeowner performing all work myself. I am a sole proprietor and have no one working.; in any capacity • ...;,ve.:..r.s+w•�r.r-�lP.^. •^J!.e�':..:�ee vl+rr..�t'S.ST,TnT^.'�lE'„j.74F��T . Ra!"', T �4 '!T!�'^-:fT a►r^... e.��._r.. �.. ..r. .. ._........:..-L - �...... :..c...r':i:o:....br:.:...�r- .'i.r�-- -%r=- ..,.2i:�:.:sr`.•- +.'�!��^w'�a'.`�'- - .�z.�1.4����' �.��..�—.W_.�._....r,....._ I am an employer providing workers' compensation for my employees working on this job. company name: Fi tc SR/, C address: C f/Z city: 00 Phone#: insurance co. polio I am a sole proprietor. general contractor, or homeowner(circle ont ) and have hired the contractors listed below who have the following workers compensation polices: company name: address: cit-: Phone#: insurance co polio # '. .. .:_•L'r:•:!� .1Y"ir.-= - '^t'•C�,•,y��....._.._ _M 2!':TSVLo�.1._. R`!•�, V�•A:r..�-�.'.. :.��.��.-._..�� company name: address- city: phone#: insurance co policy# _ :Attach additional:shce't if tiecessa'ry; ;r _-.;W'. - - :'•,:^",. _ _ i 3"!^";r'.y:.r`.^r',a ;:'` "a:�s`„ ,`r` sir-�•.--..��' Failure to secure coverage as required under Section 25A of 111GL 152 can lead to the'imposition of criminal penalties of a line up to$1,500.00 and/or one years'imprisonment as ivell as civil penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do herehv certifi•1 r er the ai id pen es perjun•that the information provided above is true and correct. Signature �� Date Print name t�'(�*%,) Phone# I � offciaPuse only do not write in this area to be completed by city or town oRcial city or town: permitAicense# M1luilding Department oLiccnsing hoard check if immediate response is required [3Scicctmcn's Office [311calth Department contact person: phone#; Mother Irn,scd 7F,i P1A) G information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers Willpensfation for their employees. As quoted from the "lacy". an einpinree is defined as every person in the service of another under anv contract of hire. express or implied. oral or written. An enrp/urer is defined as an individual, partnership, association. corporation or other legal entity. ur anv two or more of the foregoing, criga�ged in a joint enterprise. and including the lei-al representatives of a deceased emplover. or the receiver or trustee of an individual , partnership. association or other legal entity, employing; employees. However the owner of a dwellin`_ house having not more than three apartments and who resides therein. or the occupant of the 6 ellin- house of another who employs persons to do maintenance , construction or repair work on such dwelling_ house or on the _rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agencv shall withhold the issuance or renev.-al 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, neither the commonwealth nor ally 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 in the workers compensation affidavit completely, by checking the box that applies to your situation and supplying- company names, address and phone numbers as all affidavits 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. City- or Towns Please be sure that the affidavit is complete and printed legibly. Tile 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 tite applicant. Please be sure to fill in the permit/license number which will be used as a reference number. Tile affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to �_ive us a call. 75 f-..y.v..r.n.._.. ..._-...._....i-.....- .•��w.'4•.vT..::�r.a'^'.•mow:• .+wr..i-..+.....r.f�w�+••+R�:.aw.!.tsR�Ts...T.Ss.�•...�.+��w ti'_•.r..+!T.�'+fw.•i_fN:.lVl'l!T..,.-. 1'�JR•PAiwreu^...�R�' The Department's address. telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 «'ashington Street Boston, Ma. 02111 fax #: (617) 727-7749 phone #: (617) 727-4900 ext. 406, 409 or 375 A. y rP fi' 4 =`� `(�] 'Fi;i� ji�„ ESL ;`'• � l �j '•µ f I ..:; y5P1 ��a'�,' '� "�5+1`�3i.��3VS �3�;�r -Y�y'''''`. `�.r�c•�r'�r�,�`�r' r't�,t'' �` `w,.� .rr:. � a - "i z Y.. 7:a��i!, �, {r�� s' � � r �' p J� � ��� �� �". ,,,yy� ^ +moo � n� ® � ,..* �` � •'4 r e, +`a• � � ti,' V7� .4r�• �S� �.:rr W frnx�•r ,,b�F ,,�°` •c�t�x�m'.f�� /,�f�''�, 1�,� 'd ,<: fY m W ,5v` -�`D+... �„� .I fi'�}" 4,'F.� a n at 7k �``t$a ak�r� m+'s`�'r'��"' � ' ,' Nyy, �^'y .n, - i a<d ,fit.�yam''•3c'' -�a- s .� f$, ?. {y; t.. y; .fir t� tr.'ip.vk�r7d!•'�y�"'`'� AW ��-j..:y,t yx' '�.tx ' ,<:r;. �+k�ah,,9�µ� �, `a : '�`..:'`F-'� ` C 1 �!I,Yq•a� f- �7 rFmg!m;m tt,', m.9 t�} '�':�� .� ..f -Y:.:•N� f�. .. $y t���'','ei� it�,tA'. :t ��•{�', '" '��sr,'",,., r5.'..'�/C`'•�t�" 'Lr r ,��,� .2,' •-'�r"�qi U�n `ar � Nk.�,`,.'yx r r, a .. vi r�c. 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