Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0886 MAIN ST./RTE 6A(W.BARN.)
S4-, r ti� UPC 12543 % l4 No. 53LOR `�a., �� ��NS HASTINGS. MN �� i 0 ,, PyoF7HErowy TOVN OF . BARNSTABLE BAHHSTABL$ i Office of the Building Inspector 90o MEL 6 9'-`00� Date December 10, 1985 i Fee ...........2, ................................ Permit No. 128 ................................. PERMIT TO ERECT SIGN IS HEREBY GRANTED TO ..........Michael & Rosemary Messina ...................................................................................................................................................... D/B/A ..........................Gentlemen. . . ...Farmer. ....(.Gue. .s..ts. .) ................. .............. ..... .. ................................................................................... .................. LOCATION ..............886...Main.....street.....west .Barnstable........................................................................... ............................................................................................................................................................................................................... : ANY VIOLATION OF THE SIGN LAW WILL CAUSE IMMEDIATE REVOCATION' OF THIS PERMIT --'---------------------- Building Inspedor r Sii`*;ISSID" f or �T SIGN DES G1: The Architectural Review Committee (ARC) requests that each L + sLbmit ror re',-iew a fir=-=c_ business wishing 1_0 'er.ec a swan, graph, scale drawings of the si crj, and �r acket, an a �:� o=_ Barnstable Sign Application_ Sicn,. Aoplications- may be or- tained from the Building COM-71issioner ' s office , •4th door•, New Town Hall. A business ra}', at its option , suh?^it adc=- tional information which may assi st the ARC in reviewing the r the business marrng apDl!ca- sign .design_ A representative o: tion is required to attend the ARC meeting at which its sign than the minimum submission require- will be discussed. Less , met. roents will delay :action until they have been 1'- PHOTOGRAPH A photograph showing the existing . facade, on which has been indicated the proposed sign location . The photo- graph is to include a portion of adjoining stores or ` roposed building - or new facade, an builcings_ For a . p architect' s elevation. Tay be submitted in lieu of a photograph_ 2_ SCALE DRAWING OF THE PROPOSED SIGN A scale. drawing indicating 1) the type of proposed sign (wall; banging, free stzndi ng) ; 2 ) dirensionsl- of the proposed sign and any designs , logos , or lei tering; -3) colors ; the drawing may be black and white, but color chips must be -attached for colors other than black, pure white, or gold leaf ; 4 ) materials ; .1.at the proposed sign and letters are to be constructed Of; and, 5 ) a cross-section with dimensions showing edoe detail. minimum scale, 1" 1 ' . Nlirjirr"um sheer} size, 8 x 11" . Two sets. J 3. SCALE DRAWING OF THE BRACKET A scale dr awing indicating dimensions , color, material, and method of affixing it to the sign and to the bui lc- Inc. Minimum scale , 1" = 1 ' 1�11^.1r1 LT: S1ieE't 517e g x 11" _ Two, sets - 4 . TOWN OF BARNSTABLE SIGN APPLICATION A completed 'Siar . �gplication, includ_rjc scaled ciacrarr, showing location oT si an on bui ldiDc or loca_ion of ' Snow dimensions_ fre_-standinc =ian. 6 •l 5b3 ARCHITECTURAL REVIEW SIGN APPLICATION DATE `a If s TELEPHONE NUMBERS) ADDRESS OF PROPOSED PROJECT �(�CO bi OWNER MAILING ADDRESS ��p SIGN REVI fW/NAME OF BUSINESS . � r - AGENT OR CONTRACTOR - AND ADDRESS DESCRIPTION OF PROPOSED WORK(Use back of form if more space is needed) Please indicate dimensions , colors, lighting, site location, and if a sign methods of application, o a (C bLAA-Z fie_ �l9 2VnS.� FOR OFFICE USE ONLY PLEASE -DO NOT-WRITE -BELOW'THIS •LINE/CHECKEACH ITEM Sketch Attached Photographs Dimensions on Sketch Distance. from ground Illumination Method of attaching Colors Number of signs Maximum of two a . owa e 'Application Received on - ,Action Taken - - - - bate of Hearing - loe Assessor's map and lot number ...... .. ... .............. CFTHET� Sewage Permit number � ... SEPTIC SYSTEM MUST BE ""' �` INSTALLED IN COMPLIAN WITH ARTICLE II STATE HARISTLBLE Hd"use number ........................................................................ SANITARY CODE AND TO 639.a REGULATIONS. a . TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ..... �'4 3.2 c r ..........LAc..!.`.r` ...... ........................................................... TYPE OF CONSTRUCTION .....W ae?ci..........p�,A'm..... .......................................................................... ..J:�........19....: TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a +permit according to the following information: Location �?....m �./.N...... . t W es:r.��A;2rt�,� 3,Le...................................................... ....... ........ ..... .................. ............... .... Proposed Use ..... .,... .l.T.I..S!Yti�..............5.f`� !o. .60y!1.......` . Ppt.ND„ki T64� Zoning District .......... ................................................Fire District ....� .....7 ..� :�.,,....... Name of Owner ......:Qc.!?.C......E?u�..... ...�2USY......Address ......... [? .............................................................. Nameof Builder ..................... 4►r .,...........................Address .................................................................................... Nameof Architect ...................G' !Y\ e. ......................Address .................................................................................... Numberof Rooms .........o.Z.....................—.................................Foundation ......� �.'. ........... .. ....................................... Exterior W ''" � ....CAc�a'' Zs �..�-- �'e ` . ``�. ...........Roofing ........... .. �?........ Floorsl��.a ......... ................ram............................Interior .......... .N.. ,�. X .............. ............... Heating �� Se ¢c} 'Q'4.. c:d1. ..`..'�...Plumbing ..............1\ja....................................................... Fireplace .........IV-6.............................................................Approximate Cost .....� d................. ......................... Definitive Plan Approved by Planning Board _---------_---____-----------19_______. Area /........... ............................ s Diagram of Lot and Building with Dimensions Fee .:3........................................ SUBJECT TO APPROVAL OF BOARD OF HEALTH 0 IL 15� lJ I hereby agree to conform to all the Rules and Regulations of the TownArnstca,.ble regarding the above construction. Name ...... ... ... . J....................................... Teacup Realtv Trust 2057� add to dwelling No ................. Permit for .................................... ............................................................................... Location ......88b...Maiu.Zt>;eLat......................... West Barnstable ............................................................................... Owner Teacup ReAlty Trust .................................................................. Type of Construction ...............frame ........................... ................................................................................ Plot ............................ Lot ................................ Permit Granted ..... ........ September 15 19 78 ..... Date of Inspection ....................................19 Date Completed.......................................1 PERMIT REFUSED ................................................................ 19 ............................................................................... ................................................................................ ............................................................................... ............................................................................... Approved ................................................ 19 ............................................................................... ............................................................................... Assessor's map and lot number Qy�F?H E TD`' ` r Sewage Permit number ....... .L� ."° Z BAMSTODLE. i Hod-se number ro rues YAY a. TOWN OF BARNSTABLE BUILDING INSPECTOR ! APPLICATION FOR PERMIT TO . TYPE OF CONSTRUCTION 4` ::..:.. .......................... .................19........ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ...... ........................ ......... .......... ........ . ........ . ......... ....:... ...................... ........................... Proposed Use r,, ..... ......... ......... .......... ......... ....... . ........ ........................................:. ..................... Zoning District .... ... .. ..........................................................Fire District ... ........::.¢. ........................................... Nameof Owner .......................................` A....:.'.. '...::L'. .......Address ........ .... .°" :............................................................ Nameof Builder ....................................................................Address .................................................................................... .Name of Architect ........................'.::::.:>::..::..........................Address ........................................................ ....................... Number of Rooms .....................................................Foundation .......: ."'Z .— C% ........<..... ......... ........................................... Exlerior ..... ......... ..... .. ......... . ..... ...................Roofing ........: .......... ...:;..... .:................................................ Floors ...................Interior ......... . , ......... ... ...Plumbing Heating ................ .. . ...;. .:.. .::... g .................: ..:........................................................... Fireplace ..................................................................................Approximate Cost ............`........ ............................................. Definitive Plan Approved by Planning Board ---------------_—-----------19_______. Area .......................................... Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH i I hereby agree to conform to all the Rules and Regulations of the Town of"Barnstable regarding the above construction. Name .................................................................................. Teacup Redlty Trust '�*;,A=156-24 2057V,. P � dwelling.. ermit for ....................... i .t P ........................................................i�..................... t Y � t Location .............886••4aiff'.,&treet................. r Weht Barnstable' Teacup Realty Trust i Owner .................................................. Type of Construction ................................... / frame f . I ........................................ ................................... lPlot ............................ Lot ..:............................. i Permit Granted .......... eRtejnber..1.5....19 78 Date of Inspection ........... ..................19 • i Date Completed .. ............................19 PERMIT REFUSED ................................... n . �... �,...., 19 f ..................1... ` .......... ................... ........ .. . ...1'r.........� Q...... ..................... t ................ ... .G. ..... .;............................ } Approved .......................................�....... 19 ........... ........................................................ ...... ..................... ......................................................... Issessor s map and lot number Q �� doG481 .2 Z� ?7 ' ....gip..��........"......� -- _ - / SEPTIC SYSTEM INSTALLED IN C MUST BE Sewage Permit number ..12QL1G....�1[L'2.? 9. .................. WITH ARTICLE 11 COMPLIANCE SAn!ITAr STATE Q °FT"E T°,�♦ TOWN OF BARN ST�:� 'i° E '`'° TowN Ti BA$B9TA➢LE, i MA` ° 16 3 9 BUILDING INSPECTOR Opo, . \e0 'f0 ypV a' APPLICATION FOR PERMIT TO ..C .m.f..... :...?f>Qu 71r �p5e......*.... `G 5 gq�c k[nt/ TYPEOF CONSTRUCTION .... D.oa�................................................................................................................. Fe.i�f vg ......°?8 .........19.77 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Locationr..... �P ...y�'r!��1r?b ................._.............................................................................................. Proposed Use .�C�S��t�. (....1)' ?�1. ....E.. !�a�!.e.... ? r...................................................................................... Zoning District j1.P5�S#.n ?.A/............................................Fire District .60—e-I .. gru b. ................................... Name of Owner .......................Address t......Wf�..SS-��!?Y"6�s. Nameof Builder ....................Address ..:�?rr7e..................................................................... Nameof Architect ."'WL ?A;...................................................Address .., ?m ................................................................... Number of Rooms "2' ..Foundation ..5A ..... IO !'c ........�(O.. � y74w'4 Exterior 5C4L.f Y C. .. /�i?f. X�v�c /�/ 35/�'IS.Roofing ..Q�Or k.../P// two .................... ............................................................ Floors --// J am f?Y..................................................................Interior p. ............................................................ Heating ../1.G.!1.e...................................................................Plumbing ....1?.4.1?9................................................................. p �� ..................................Approximate Cost ..... /.f!L��r..PO Fireplace .r?D.......................................... �... r �. .......... i Definitive Plan Approved by Planning Board r14�1�__I1cCQ Gr�!____19________. Area ..L.6. Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH fz a// X y /6 'ion r► wo/% SIVC45 f00 �le rs / v c. Ste Gov, yx 6 " s�f/oaf 6 jv/�forf�i'� I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. l� Name !�"` ........�`..G ,�OJ`.... .. .......................... Bryson, Lynda A. Type of Construction frame.............................. ................................................................................ Plot ............................ Lot --------'—.. - � - Permit Granted —.Mhurcb..��....................lA 77 ' Dote of Inspection —.---.l9 Date Como���6 ..�����/�[.,�..�J�--.]g . PERMIT REFUSED ----..----.----------..--. lR ~^'—^~^--^^----'-------^^----`^' ----------------'------'---- ' -'—'-----'—'-------------'—'-- -'—'-----'----'---------'---'- r� - Approved � .................................................. l9 . --------~'----^^^^^'—^'''---^^~'~—' ............................................................ N Assessor's map and lot number ....... ......: .... ,% Sevrge Permit number .......................................................... 'THE.T TOWN OF BARNSTABLE 1; BAREST"LE, i 16 BUILDING INSPECTOR �'0 YPY a• APPLICATION FOR PERMIT TO "� TYPE OF CONSTRUCTION ............... ....... ............19........ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .........................................................::::.............................................................................................................. Proposed Use .....':. .............. c o ..... ....... ......... Zoning District o...........................................Fire District ..............:. ...................... ....................................... Nameof Owner ........................ ......... ..... ........................Address .....:. .......:. .............:................................................ Nameof Builder .............. .......................5` ....................Address ....... ......................................................................... Nameof Architect ...:..............................................................Address .................................................................................... Number of Rooms ...... '.::'.......................................................Foundation .. :!.::. ..............:...: ................ Exierior ..Roofing ............................................. Floors ....................................................................Interior ...... ..;:.::...`.... .............................................................. Heating ......:......:....................................................................Plumbing .............................................................................. Fireplace .. .....................................................................Approximate Cost ... ....................Definitive Plan Approved by Planning Board -------------------___--__:-_--19--------. Area - ................................ Diagram of Lot and Building with Dimensions Fee ...................................... SUBJECT TO APPROVAL OF BOARD OF HEALTH s I I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .. .: : .... ......�.. ............,_ .......................... Bryson, Lynda A. M156 L24 '061 No .... Permit for P.QPX ry.Aq. e... .,shed pQvl.zxy..klQus.�..1md..:;; 4 gq.. hed....... Location ABA..Ma.3.n..$.trBBt........ . .................. ........West..Barns.tablp...................................... Owner ......1.ynda...A...Arys.QA.......................... Type of Construction ..Iram............................. ................................................................................ Plot ............................ Lot ........ ° 4 Permit Granted March .. .....1977 h ........................ . Date of Inspection ......�........................19 Date Completed ......................................19 '> �PERM, REFUSED ........ 19 ............ .. .. ....... .. .. ..%. ......... .. .... ......... .... ... ......... • ••.......................... ...... ..F. .................................. Approved ' ....................................... ` .............................. . i r 22 �1rr t Application number.......I ..Iy..... o�. �1... *+ Date Issued................eD.( IIl... vN Building Inspectors Initials......... ....... Map/Parcel....1.....J..S�?...:.Q. �{........ ..�. TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: V1 G Sfi Day Ul!ML V4-, NUMBER STREET VILLAGE _ Owner's Name: +4a t l Q T r, p�e� Phone Number r -'36 4,- g S sI MKT H l cif .Email Address: wi Cell Phone Number Project cost $ 2-01 000 Check one Residential V Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize Z-a Ki V to make application for a building permit in accordanc&with 780 CMR Owner Signature: Date: TYPE OF WORK Siding "Windows (no header change)# 0 Insulation/Weatherization 0 Doors (no header change)# Commercial Doors require an inspector's review Q Roof(not applying more than 1 layer of shingles) Construction Debris will be going to ti.n.5, 5'fm-, � t CONTRACTOR'S INFORMATION Contractor's name .�0 c. 1�,L h Home Improvement Contractors Registration(if applicable) (attach copy) Construction Supervisor's License# (2—s 5 L w 9 q (attach copy) Email of Contractor Phone number s�-2-7 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 PERMIT CAN BE ISSUED. APPLICATION NUMBER...................................................::....... *For Tents Only* Date Tent](s)will be erected Removed on number of tents total Does'tlie 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 APPLICANT'S SIGNATURE Signature Date All permit applications are subject to a building official's approval prior to issuance. f 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 Joe Kong Please Print Legibly Name(Business/Organization/Individual): 36 Checkerberry Lane West Yarmouth, MA 02673 Address: age 602-775-6442 City/State/Zip: Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2. I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling s 'p and have no employees These sub-contractors have g• ❑Demolition workingfor me in an capacity. employees and have workers' Y P ty• t 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• ther W I w�oLVS comp.insurance required.] S I tLl Vj *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi under the pains and penalties ofperjury that the information provided above is true and correct Si ature: Date: /v lb. Phone#: 4 U ' z 7 5�-- 1 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#: 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 appurtenani thereto shall nbt because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit'to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their 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 pern it/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington.Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia f - • �%ME, Town of Barnstable Building Department Services 33ALaxer-4J3 . ` Brian Florence, CBO xAs& 163g6 �0�' Building Commissioner En ram'' 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section - If Using A Builder L —5a r\ , as Owner of the subject property hereby authorize to act on my beb.A. in all matters relative to work authorized by this building permit application for. ece' o r'5 (Address of Job) 4 ' **Pool fences and alarms are the responsibility of the applicant Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted.. Signature of Owner Signature of Applicant Print Name Print Name Date Q:FOR AS:0WN MPERMISSI0NP00IS Rev:08/16/17 Town of Barnstable wilding Department Services . Brian Florence,CBO ' o Balding Commissioner 200 Main Street, Hyannis;MA 02601 IMENSTAMMXASX ," www.town.barnstable.ma.ns s63q. � Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE ESEI4IMON Please Print DATE: JOB LOCATION: numbert. ° "HOMEOWNER": name home phone# work pbone# CURPJWT MAZWG ADDRESS: c4hown. 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 EQervisor. DF.F]=ON 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 structmes'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 bwlding 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 Bamstable Building Department minimum inspection procedures-and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control HOMEOWNER'S FXEM[ ZTON 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 helshe understands the responsibilities of a Supervisor. On the last page this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q.\WPFILES\FORMS\building pmmit fnrms\E)TRESS.doe 09/16/17 Commonwealth of Massachusetts Division.of Professionaf"Licensure Board of Building Regulations and Standards ConstructiDO*' N%S�rSpecialty CSSL-099166 �> fires: 01/24/2020 i JOSEPH E KING ;` n 36 CHECKERBERRY WEST YARM06TH'MA�02673 ��`t�lSSq^I01 , Commissioner CL �innrciui ea�l�o�./liLtck�¢�iJel(� Office of Consumer Affairs 8 Business Regulation Registration valid for individual use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found'retum to. TYPE:1Individual Office of Consumer Affairs and Business Regulation Registratiori, Expiration One Ashburton Place-Suite 1301 150889-: 05/04/2020 Boston,MA 02108 JOSEPH E.KING _ JOSEPH E.KINGS ' 36 CHECKERBERRYi N va id without s' tur@ -W EST YARMOUTH,MA-02673 U Undersecretary t NOW f J a/ Fo'u �Jr r 01 a 3± Acres + -j ti L I N Q L +� M ` i f 0 A Flo y 2 � o p ' Y v MORTGAGE SURVEY- PtA� c "eye Location B A R N STAB _ )l<.-, 14312 rec ,z scar* i in.,-10o tt. Dats .too y.1.3,,1Si?6- �, t 1 5 6.67 Plan niereaa: 8einq,,.dssgrj.0e,0 186 eed _AY.. 4,d„ ., - . D 08 Fbcordad, ..in. Born:t�oble R.%NlryOf.;De Book -A5W,. .P49e ......... ... .... MAIN ST. ... ... . . ....:...... . .; RTIFY THAT YME PREMISES _ 0 171- PLAN 4 ARE t^iOT LOCATED WITH- JOSEPH SELWY'N, Civil Engineer. L; ^Jt� +:SARI' �Of.E t, ?EIihEAT£D 14 Linden Avenue, Belmont t 1I T *�!i ?C�Il 11A1 •n t f��r• ,, b+.+..� �.:V+I I.'�}' C�i1r� iK LS a.i.: I hereby certify that the building shoWa.on � 7 i�'7. plan is located on the ground as Gown tdtenqu i and LhaL it conforms to the aoni7ag and bush W3 �� •. 'l laws of the town of Barnstable when constructed and to restri74iW on record. M,4 ptot picrr w a, r..n mada L-t n an lastrumont survey and is drown �f 'nr i for 'he .rr or ti-, x, .tan ,,.. ..�.t, a -ucxcp naly C- .,7 t r- Town of Barnstable _ Building ...,. : r ... 1 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"9 Posted Until Final Inspection Has Been Made.039. Permit ° Where a Certificate of Occupancy is Required,such Building shall Not be Occupied until a Final Inspection has been made. Permit No. B-17-4320 Applicant Name: RETROFIT INSULATION, INC. Approvals Date Issued: 12/26/2017 Current Use: Structure Permit Type: Building-Insulation-Residential Expiration Date: 06/26/2018 Foundation: Location: 886 MAIN ST./RTE 6A(W.BARN.),WEST BARNSTABLE Map/Lot: 156-024-001 Zoning District: RF Sheathing: Owner on Record: CLARKE,ALAN R&GLORIA M Contractor Name JOSEPH J REILLY Framing: 1 Address: BOX 722 Contractor License: CSSL-102771 2 WEST BARNSTABLE, MA 02668 F Est. Project Cost: $ 10,262.00 Chimney: Description: weatherization ~^ Permit Fee: $ 102.02,I Insulation: Project Review Req: ! Fee Paid: $ 102.02 Date: 12/26/2017 Final: wl � 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: Rough: 1.Foundation or Footing 2.Sheathing Inspection Final: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough: 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Final: 7.Final Inspection before Occupancy Health Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT r TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION CY Map Parcel Application # 9 3 Health Division Date Issued 7-? a 7117 /W 4A. Conservation Division Application Fee Planning Dept. Permit Fee / Date Definitive Plan Approved by Planning Board l ` a /ppd Historic - OKH Preservation/ Hyannis Project Street Address Village r Owner_ __A0(10 i ' 14,6 Address ��L -Pt-)^J D7 Telephone(ak) Permit Request 0 A,C— Leal f%yr /Q, 1 1 -`f a,_ �e l 69p �_ " Rt6lo Za, �6� r✓Ll�J)GC� 6x k t ,vim l,v q'L lr 69�''2�J l i p cs� — l o (!, o o 1'S o J`QA� Square feet: 1 st floor: existing proposed 2nd floor: existing proposed O Total new co Zoning District Flood Plain Groundwater Overlay z ® C- ri R7 Project Valuation U 2� -7 Construction Type M Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting,documentation. �, � CJ' Dwelling Type: Single Family 0--/ 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 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 ❑ Oil ❑ Electric ❑ Other Central Air: ❑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 0 Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name 126? :fi 7evr`��' ��� Telephone Number C�)�j�l 6 `-"03C Address l"d 12 ok pa` License # / 0_)''? Home Improvement Contractor# l 6, y Email f 4 9 nc- c-— Worker's Compensation # 01 /(o 42 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO ✓i rn arm L SIGNATURE V DATE FOR OFFICIAL USE ONLY : APPLICATION # DATE ISSUED MAP/ PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL r, GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT. ASSOCIATION PLAN NO. The Commonwealth of Massachusetts ' UVDepartment of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Ledbly Name (Business/Organization/Individual):RetroFit Insulation Address:PO Box 105 City/State/Zip:Seekonk, MA 02771 Phone#:508-989-6436 Are you an employer?Check the appropriate box: 'Type of project(required): 1.❑✓ I am a employer with 1 employees(full and/or part-time).' 7. ❑New construction 2.❑1 am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling any capacity.[No workers'comp.insurance required.] 9. El Demolition 3.R I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 4.❑i am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.E]Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.� p Roof repairs These sub-contractors have employees and have workers'comp.insurance.t 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.E]Other Weatherization 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. rContractors 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:STAR Ins. Policy#or Self-ins.Lic.#:V9WC802160 Expiration Date:8-2-18 Job Site Address:886 Main St. City/State/Zip:Barnstable, MA 02668 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). 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$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct. Signature: Date: 12/05/17 Phone#:508-989-6436 Official use only. Do no ite in tit' 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#: D,ocuSign Envelope ID:F9EC4995-OE99-4A13-9CF6-8D2FC3DO55F7 rNE Ta Town of Barnstable .;° ray, �. ���, Regulatory Services . a3ARNSTABL), .' Richard V. Scali,Director MASS, o; Building Division Paul Roma Building Commissioner 200 Main Street,Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section I, ROBERT HALLETT , as Owner of the subject property hereby authorize Retrofit Insulation to act on my behalf, in all matters relative to work authorized by this building permit application for: 886 Main Street West Barnstable, MA 02668 . (Address of Job) DocuSigned by: 11/15/2017 8:51 AM EST CDFD18520101 F Signature of Owner Date Robert Hallett Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form. C:\Users\decollik\AppData\Local\Microsoft\Windows\1NetCache\Content.Outlook\L7U69LF2\EXPRESS(2).doc 01/25/17 Office of Conger Affairs and Business Region 10 Park Plin-Suite 5170 Boston,Mas 02116 ROB IoVOMC11t tea: Roott'att.On . R 180�8h �: Pftte Cor� lengo : 7TR018 '11Y 2B9[6 RETROFIT INSULATION INC. JOSEPH REILLY .y:. �' „Y•= ` =�j P.C. BOX 105 ------------ SEEKONK, ILIA 02771 ����a� �„ ,y;/` 17pdate Ad rro and retara rsard.Mak rows for dwWL ❑AOMM p Rmwst p XxP ❑Loft card SCAl eA. ,ra err a r Gra, ucam VILE i for w up only 0Wm atCmnmwAfttn& 6e� lromd rsbun 103 COMTRAMOlk pS**of Common Al8sin amd Badsm a ,'fir jopok ^�3170 . 8 Pds►M cams atlan Dams,MA 0116 RETROFIT + , 844 ROOMM 8T t ypt' ■" Not LIM witho t ro FALLfSVEli MA0Z7x� Un� S' I I 4 t `i i { t i i 7 } i 1. f I y Commor'i4eaith of Massachusetts Division of Professional licensure Board of Building Regulatiians:and Standards Constructi¢a�j,`Sjoff fsor Specialty GSSL-102 71' P pines:06/05/2010 JOS�PH J R t lY Po 8OX io6. SEEKOIUK NIA Cummissioner �/""" ✓ r i r • �-'� RETRINS-01 DCARVALHO .A�C`ORD" DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE oE;MMID IYY 17 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 License#1780862 CONTAME:ACT Diane Carvalh0 HUB International New England PHONE FAX 222 Milliken Boulevard (A/C,No,Ext): (A/C,No): Fall River,MA 02721 A DRIEss:diane.carvalho@hubinternational.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Selective Insurance Company of South Carolina 19259 INSURED INSURER B:National Liability&Fire Insurance Company 20052 RetroFit Insulation,Inc. INSURER C PO Box 105 INSURER D: Seekonk,MA 02771 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. INSR LTRTYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE �X OCCUR S 2187653 08/15/2017 08/15/2018 DAMAGE TO RENTED 100,000 PREMISES Ea occurrence $ MED EXP(Any oneperson) S 5,000 PERSONAL&ADV INJURY $ 11000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY❑JR LOC PRODUCTS-COMP/OPAGG $ 2,000,006 PE OTHER: $ A AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1,000,000 Ea accident) $ ANY AUTO A 9100182 08/11/2017 08/11/2018 BODILY INJURY Perperson) S OWNED SCHEDULED AUTOS ONLY X AUTOSSWN BODILY INJURY Per accident $ X AUTOS ONLY X AUTOS ONLY PeOraEccRtlen DAMAGE $ $ A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE S 1,000,000 EXCESS LIAB CLAIMS-MADE S 2187653 08115/2017 08/15/2018 AGGREGATE 5 1,000,000 DED RETENTIONS I $ B WORKERS COMPENSATION - STIR U E ORH- AND EMPLOYERS'LIABILITY YIN V9WC802160 08/02/2017 08/02/2018 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L.EACH ACCIDENT $ ?Me IC RIMoryEn BE EXCLUDED? NIA 1,000,000 E.L.DISEASE-EA EMPLOYE $ It yes.describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 5 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE National Grid THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 40 Sylvan Road 02451 AUTHORIZED REPRESENTATIVE ACORD 25(2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Mass. Corporations, external master page Page 1 of 2 William Francis Galvin Secretary G J of • • of sew a� Corporations Division Business Entity Summary ID Number: 000993448 Request certificate New search Summary for: QUAKER RUN CRANBERRIES LLC The exact name of the Domestic Limited Liability Company (LLC): QUAKER RUN CRANBERRIES LLC Entity type: Domestic Limited Liability Company (LLC) Identification Number: 000993448 Date of Organization in Massachusetts: 01-09-2009 Last date certain: The location or address where the records are maintained (A PO box is not a valid location or address): Address: 20 TREE TOP CIRCLE City or town, State, Zip code, MARSTONS MILLS, MA 02648 USA Country: The name and address of the Resident Agent: Name: ROBERT HALLETT Address: 22 ACORN DRIVE City or town, State, Zip code, OSTERVILLE, MA 02655 USA Country: The name and business address of each Manager: Title Individual name Address MANAGER ROBERT HALLETT 20 TREE TOP CIRCLE MARSTONS MILLS, MA 02648 USA In addition to the manager(s), the name and business address of the person(s) authorized to execute documents to be filed with the Corporations Division: Title Individual name Address SOC SIGNATORY SEAN HALLETT 20 TREE TOP CIRCLE MARSTONS MILLS, MA 02648 USA The name and business address of the person(s) authorized to execute, acknowledge, deliver, and record any recordable instrument purporting to affect an interest in real property: http://corp.sec.state.ma.us/CorpWeb/CorpSearch/Corp$ummary.aspx?FEIN=000993448... 12/14/2017 Mass.,Corporations, external master page Page 2 of 2 Title I Individual name Address REAL PROPERTY ROBERT HALLETT 20 TREE TOP CIRCLE MARSTONS MILLS, MA 102648 USA ❑ ❑Confidential ❑Merger ❑ Consent Data Allowed Manufacturing View filings for this business entity: ALL FILINGS Annual Report ' Annual Report - Professional Articles of Entity Conversion Certificate of Amendment v j View filings j Comments or notes associated with this business entity: d New search) http:H,corp.sec.state.ma.us/CorpWeb/CorpSearch/CorpSummary.aspx?FEIN=000993448... 12/14/2017 1 of1KZ .Town of Barnstable *Permit # E.rpires 6 nrontlis from issrre dale • akaNsrABLF_ Regulatory Services Fee MAM Thomas F. Geiler, Director i639' Building Division Tom Perry, CBO, Building.Commissioner 200 Main Street, Hyannis, MA 02601 p wwrv.town.barnstab le.ma.us U Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY /� Not Valid without Red X-Press Imprint Map/parcel Number � 00 0-4 Property Address 22& M.A t tj -j-er eqv�cs��.Q eesidential Value of Work. Minimum fee of S25.00 for worlc under S6000.00 Owner's Name& Address A law %QCe' VA3U-c !''i lW eAl2_S' 4A A I e Contractor's Name 6-Al S!t�r/�l 4e2 Telephone Number ��c�'�it t aa7� � Home Improvement Contractor License#(if applicable) Construction Supervisor's License# (if applicable) ❑Workman's Compensation Insurance -PRESS PERMIT Check one: ❑ I am a sole proprietor SEP 1 200� ❑ I am the Homeowner have Worker's Compensation Insurance TOWN OF BARNSTABLE Insurance Company Name-! t f a- /At4,A 11 Workman's Comp. Policy 4 '7 q 1-)6 Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) P"Re-roof(stripping old shingles) All constr ction t ebris will be taken to ❑ Re-roof(not stripping. Going over existing layers of rood ❑ Re-side ❑ Replacement Windows. U-Value (maximum .44) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Y e rovement Contractors License& Construct Supervisors License is required. SIGNATURE: :4;Z., Q:\WPF1LES\FORMS\Express\EXPRES SPERM IT.DOC Revise06O4O9 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 Legibly Name (Business/Organization/Individual): _Jf�•S/��j ,�QL+ i Address: 3 I X�e(d oD o 'D 11 - City/State/Zip:.4 c(, Phone M 11-3Q J01 Arwlam an employer?Check the appropriate box: Type of project(required): 1. a employer with 73 4. ❑ I am a general contractor and I 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees . These sub-contractors have 8. ❑ 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 I LE] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. • oof 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 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: lse_ /yo U o c Policy#or Self-ins. Lic.#:Lic a n f 3 ya q/ 77 0t'ef Expiration Date: M Job Site Address; A�I 54 City/State/Z1p��,. _ ��1 Idle A//A 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 cer ' unde pa sand penalties of perjury that the information provided above is true and correct. `4 Si nature: Date: /4 Phone#: S6 8 `t d /« 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#: f 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-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships (LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in.any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to,give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 4-24-07 www.mass.gov/dia �,ME Tp Town of Barnstable Regulatory Services �$^MMAS& 8' Thomas F.Geiler,Director o ;t►�` Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.b arns table.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, A L a a el A as Owner of the subject property hereby authorize j 1�e;,��o to act on my behalf, in all matters relative to work authorized by this building permit application for. (Address of Job) /cv \Signature of Owner Date %Ll' /V rint Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. i Q:FO RM S:O W N ERP E RM I S S I ON Town of Barnstable o Regulatory Services BARNSTABLe Thomas F.Geiler,Director MAss. 9� 039. ��� Building Division • pTED��p 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: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: 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. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) 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\FORM S\homeexempt.DOC s NOTICE R NOTICE i TO TO ==EMPLOYEES EMPLOYEES Y µ r i The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 - http://www.mass.izov/dia As required by Massachusetts General Law,Chapter 152,Sections 21, 22& 30, this will give you notice that I (we) have provided for payment to our injured employees under the above-mentioned chapter by insuring with: LIBERTY MUTUAL INSURANCE CO NAME OF INSURANCE COMPANY PO Box 9102 Weston, MA 02493-9102 1-800-762-5026 ADDRESS OF INSURANCE COMPANY i WC1-31S-342974-039 04-26-2009 04-26-2010 POLICY NUMBER EFFECTIVE ATES i MARK T VOKEY INSURANCE AGENCY (508) 945-3535 NAME OF INSURANCE AGENT PHONE # PO BOX 1247 WEST CHATHAM MA02669 ADDRESS OF INSURANCE AGENT JOSEPH JACINTO DBA SEASIDE 3 LAKEWOOD DRIVE EMPLOYER ADDRESS EMPLOYER'S WORKERS'COMPENSATION OFFICER (IF ANY) DATE MEDICAL. TREATMENT The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish adequate and reasonable hospital and medical services in accordance with the provisions of the Workers'Compensation Act. A copy of the First Report of Injury must be given j to the injured employee.The employee may select his or her own physician.The reasonable cost of the services provided by the treating physician will be paid by the insurer,if the treatment is f! necessary and reasonably connected to the work related injury.In cases requiring hospital attention, employees are hereby notified that the insurer has arranged for such attention at the I NAME OF HOSPITAL ADDRESS Y -r TO BE POSTED BY EMPLOYER Insured Copy It f r il9assachusetts-Board of Buil Deprtment of Public Safeh;`:din'-Regulations and Construction Supervisor S Standar'dti si License: CS SL 99163: Pecialty License .,;5ZI Restricted to:t RpwS JOSEPI-I N' � k ACINTO 3 LAKEWOOD•DRIVE i HARWICH'MA 02645 -1 I „mmisiui�r'r, Expiration 10l7i20t1.. H Tr#:-99163 - ----------- -- ii �\ Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration1138539 Ezplratton4l1112011 Tr# 282017 <i ; ^� e_DB� . SEASIDE ROOFINGAND.SIDING€ ! .Q EPH JACINTO I OD DR. :', < "Z, HARWICH,MA 02645 ni Admistrator 6 ?: y License or registration valid for individul use only before the expiration date. If found return to: ; Board of Building Regulations and Standards i One Ashburton Place Rm 1301 ' Boston, .Ma 02108 • � #� . '?t Not valid without signature • ' .. ' :1 TOWN OF BARNSTABLE SIGN APPLICATION 19 � Owners Name Address tM / Location Name of Builder COb 5�6A/ C-0, Address Type of Construction ee Stan i or Attached _ Zoning District ��� Fire District W &9—R Sm"0) I hereby agree to conform to all Rules and Regulations of the Town of Barnstab regarding the bove construction. All permits subject to approval of the Inspector of Wires. 1 Name Diagram of Lot and Sign with Dimensions to be placed on reverse side. SZ SQ. b c