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2135 MEETINGHOUSE WAY/RTE 149
i i� i �I j� i O.xfordNO. 152 1/3 ORA ra --• ,- � .-�.. .. ,.�,, .. - _- - _ 1, _ - r _ 2135 MF�i�Jlal�Dt[�. u�'�-Y�2rE /'spy ' w �sr 8�taysr � �: �; t, t. I k- f. Application number. (AO....... /10......... ............................ Fee MIUM` KAM AZ't' ` Building Inspectors Initials ............................. Ak MAY 1 o Zpig 11ff Date Issued...��13.1.J..�. IOR/N 1AdAHNU f- BL 2 ...................................... Map/Parcel...........�Y.V. DI TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: o2& Uy 6 _// 6 6y• 6 NUMBER VSTREET VILLAGE Owner's Name: Phone Number���'-°�� -�„�9 6. I-u F Email Address: d P,spo Cif �yS i c'c��Cas Cell Phone Number ,�0�°-366 - ,z?, 7 Pr 'ec cost . T Z7 C/ o� t os $ ,S Check one Residential_ Commercial 9tr-�-- OWNER'S AUTHORIZATION As owner of the above property Y I hereby authorize g"4. &C� P to make application f buil ' g pe t ' ccordance with 780 CNM Owner Signature: Date: 5 TYPE OF WORK ❑ Siding O1�indows (no header change)#_�❑ Insulation/Weatherization ❑ Doors (no header change)# Commercial Doors require an inspector's review ❑ Roof(not applying more than 1 layer of shingles) Construction Debris will be going to CONTRACTOR'S INFORMATION Contractor's name Home Improvement Contractors Registration(if applicable)# (attach copy) Construction Supervisor's License# C S OS 6 7.3' 7 (attach copy) Email of Contractor S'CG Go /k u 1 / Phone number S'0 P 3G �6-54q ZOO ALL PROPERTIES THAT HAVE STRIJCTURES 0 V4175 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............................................................ *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides? Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes —No-- - -- - Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s)of each tent Fuel source being used LP tank 20 lbs. or>Yes No , if yes, a gas permit is required. Natural Gas Yes No if yes, a gas permit is required. 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 CAM the Massachusetts State Building Code. I understand the construction inspection procedures, specific inspections and documentation required by 780 CAM and the Town of Barnstable. Signature Date APPLICANT'S SIGNATURE Signature �� Date 2aAa2 All permit applications are subject to a building official's approval prior to issuance. The Commonwealth of Massachusetts t Department of Industrial Accidents 7. -- Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le 'bl Name(Business/Organization/Individual): Address: City/State/Zip: — Phone#:_ Are you an employer?Check the appropriate box: Type of project(required): 1.El I am a employer with 4. ❑ I am a general contractor and I �,e�loyees(full and/or part-time).* have hired the sub-contractors 6 ❑New construction 2. a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g• ❑Demolition workingfor me.in an capacity. employees and have workers' Y P tY• # 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 L❑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 w I,kU�-J comp.insurance required.] r e K *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy informati n. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: D Job Site Addresso?135 R-4 City/State/Zip: �r�7 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains �enaltlesthat the information provided above is true and correct Si ature: Date: �r Z Phone#: Official use only: Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage.required." . Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and.fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of lnve4tigations 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 i Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constructiori'Upervisor CS-056737 Expires: 02/05/2021 e MICHAEL S SULLIVAN' 497 A RT6A EAST SANDWICH MA 02537 r�. Commissioner C "`^" Town of Barnstable,Planning&Development Department Old King's Highway Historic District Committee ' 200 Main Street,Hyannis,Massachusetts 02601 Phone 508.862.4787 Email erin-logaii@toN.vn.bamstable.ma.us CERTIFICATE OF EXEMPTION Application is hereby made,with four(4)complete sets,for the issuance of a Certificate of Exemption under Section 6 and 7 of Chapter 470.Acts and Resolves of Massachusetts,1973,as amended,for proposed work as described below and on plans,drawings,or photographs accompanying this application: Date 9 Address of Proposed work, Assessor's Map and lot;1 House 1# 3 S Street AULo &x , �'�(d�/ Village: This application is for an exemption of the proposed construction on the grounds that work: ❑ Will not be visible from any way or public place ❑ is within a category declared exempt by the Old Kings Highway Regional Historic District Commission 9 Other Description of Proposed WcA: 0��✓- s Agent or contractor lease print): g�P Tel.no. �d� "�t;�/' ` a p a Address 7 / A' J(.-V Owner(please print):w to o Tel no. Owners mailing address: v h C P Signed,Owner/Contractor/Agent G � n ./Irtaf• Checklist (J ❑ Four complete sets of the application and supporting documentation u $ Filing Fee(see attached schedule) For Committee Use Only This Certificate is hereby APPROVED/DENIED Date: Committee Members Signatures: Conditions of approval: p (� Olil/Exemption Form 2017 �- � �- - �� % `� rr , r I � CV t. z —; ir tt • '.e ITII --a a t t c �T�^ :� _ftir • i 1 } i�. 0002405E BODC: TE MEETINGHOUSE FARM INC C/O JUDITH DESROCHERS PO BOX 330 ��.. W BARNSTABLE MA 02668 gyp: :4333 Employer ID Number : 20-1230499 Form 990 required: Yes Dear Taxpayer: This is in response to your request, dated June 23, 2016, regarding your tax-exempt status . We issued you a determination letter in June 2005, recognizing you as tax-exempt under Internal Revenue Code (IRC) Section 501(c) (3) . Our records also indicate you' re not a private foundation as defined r unde IRC Section 509(a) because you' re described in IRC Sections 50;9Ca) and' 170-(b) (1) CA) Donors can deduct contributions they make to you as provided in IRC Section 170 . You' re also qualified to receive tax deductible bequests , legacies , devises, transfers , or gifts under IRC Sections 2055 2106 , � and 2522. In the heading of this letter , we indicated whether you must file an annual information return. If a return is required, you must file Form 990 , 990-EZ, 990-N, or 990-PF by the 15th day of the fifth month after the end of your annual accounting period. IRC Section 6033(j ) provides that , if you don't file a required annual information return or notice for three consecutive years, your exempt status will be automatically. revoked on the filing due date- of the third required return or notice. For t.ax� f.orms., ..instructions, and publications, visit www.irs .gov or call 1-800-TAX-FORK! (1-800-829-3676) . If you have questions, call 1-877-82'9=5500 between 8 a .m. and 5 p.m. , local time, Monday through Friday (Alaska and Hawaii follow Pacific Time) . �;, " F: The Home Depot Special Order Quote , 5+, Customer Agreement#: H2622-113216 A " Printed Date:4/1/2019 Customer: JOSEPH LEARY Store: 2612 Pre-Savings Total: � Address: 695 MAIN ST Associate: JASON Total Savings: � If WEST BARNSTABLE,MA 02668 Address: 65 INDEPENDENCE DRIVE Pre-Tax Price: !' Phone 1: 774-994-0097 HYANNIS, MA 02601 Price Valid Through: Phone: 508-778-8948 4/10/2019 Phone 2: 774-994-0097 7- All prices are subject to change. Customer is responsible ftrifying product selections. The Home Depot will not accept returns for the below products. Standard Width=Custom A erican Standard Height=Custom C man° �.w.. Frame Width= 29 Frame Height=56 no 9 M. 100-1 70 Series NF Double-Hung-3001,3901 Equal Sash,AA,29 3 A Y �Rx 56,White%White Begin Line 100 Description —Line 100-1— 70 Series NF Double-Hung-3001,3901 High Altitude Breather Tubes=No Foam=No Overall Rough Opening=29 1/2"x 56 1/2" Glass Strength=Standard Drywall Return=No Overall Unit=29"x 56" Glass Tint=No Tint Vinyl Sill Angle=None Installation Zip Code=02601 Specialty Glass=None Head Expander=No U.S.ENERGY STAR"Climate Zone=Northern Gas Fill=Air Extension Jamb Type=None ENERGY STAR Required=No Contour Grilles-Between-the-Glass Re-Order Item=No Standard Width=Custom Specified Equal Light Room Location.=Custom Location Standard Height=Custom Grille Pattern=Specified Equal Light Custom(Enter Room Name)=Barn Frame Width=29 Exterior Grille Color=White Unit U-Factor=dA6 Frame Height=56 Interior Grille Color=White Unit Solar Heat Gain Coefficient(SHGC)=0.55 Venting Handing=AA 4W3H U.S.ENERGY STAR Certified=No Exterior Color=White Number of Sash Locks=Single SKU=239574 Interior Finish Color=White Lock Type=Standard Vendor Name=S/O SILVER LINE BLDG PRD Performance Rating=PG50 Window Opening Control Device=No Vendor Number=60660514 Glass Construction Type=Dual Pane Insect Screen Type=Full Screen Customer Service=(888)504-0005 Glass Option=Clear Dual Pane Insect Screen Material=Fiberglass Catalog Version Date=11/26/2018 End Line 100 Description Page 1 of 2 Date Printed:4/1/2019 21:39 AM i Standard Width=Custom —=1 Standard Height=Custom Arrrican t- , Craftsman' Frame Width=23 Frame Height=40 -. 200-1 70 Series NF Double-Hung-3001,3901 Equal Sash,AA,23 $200.03 $170.00 2 ($60.06) $340.00 x 40,White/White I I F .f U. •f /1 Begin Line 200 Description —Line 200-1- 70 Series NF Double-Hung-3001,3901 High Altitude Breather Tubes=No Foam=No Overall Rough Opening=231/2"x 401/2" Glass Strength=Standard Drywall Return=No Overall Unit 23"x 40" Glass Tint=No Tint Vinyl Sill Angle=None Installation Zip Code=02601 Specialty Glass=None Head Expander=No U.S.ENERGY STAR"Climate Zone=Northern Gas Fill=Air Extension Jamb Type=None ENERGY STAR Required=No Contour Grilles-Between-the-Glass Re-Order Item=No Standard Width=Custom Colonial Room Location=None Standard Height=Custom Grille Pattern=Colonial Unit U-Factor=0.46 Frame Width=23 Exterior Grille Color=White Unit Solar Heat Gain Coefficient(SHGC)=0.55 Frame Height=40 Interior Grille Color=White U.S.ENERGY STAR Certified=No Venting/Handing=AA 3W2H SKU=239574 Exterior Color=White Number of Sash Locks=Single Vendor Name=S/O SILVER LINE BLDG PRD Interior Finish Color=White Lock Type=Standard Vendor Number=60660514 Perf_ormance_Ratin_g=PG50 _ Window Opening Control Device=No Customer Service=(888)504-0005 -- - - - -- _ -- -- --- Glass Construction Type=Dual Pane Insect Screen Type=Full Screen Catalog Version Date=11/26/2018 ' Glass Option=Clear Dual Pane Insect Screen Material=Fiberglass End Line 200 Description I Page 2 of 2 Date Printed:4/2/201911:39 Al &&72.519? Application number.. r 0.1' Fee .........................r-2.5...............................�...... { RARAM,STAOLL Building Inspectors Initials...... q. .....P— Date Issued.......C..�. .......................... . Map/Parcel................................................................. TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDO WS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: 2 / � UV �ilt2s NUMBESTREET VILLAGE Owner's Name: Ph Ice Number Email Address: Cell Phone Number Project cost $ Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize BUII_DNIG DPP7 to make application for a building permit in accordance with 780 CMR Owner Signature: Date: AUG 10 2018 TOWN OF p p ,- TYPE OF WORK 0 Siding D Windows (no header change) # 0 Insulation/Weatherization E-1 Doors (no header change) # Commercial Doors require an inspector's review E-1 Roof(not applying more than 1 layer of shingles) Construction Debris will be going to CONTRACTOR'S INFORMATION Contractor's name Home Improvement Contractors Registration(if applicable) # (attach copy) Construction Supervisor's License# (attach copy) Email of Contractor Phone number 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. Town of Barnstable Building Post This Card So"That it is U�sible From the Street App"r."oved Plans Must be>Retained on Joii and this Card,Mustb`e p X K M" Posted Until'Final Inspection Has Been Made ,a3a = .. Permit Where a.Certificate°of Occupancy is Required;such Building shall Not be Occupied until a Final Inspection has-been made: ' Permit No. B-18-2597 Applicant Name: BARNSTABLE,TOWN OF(LB) Approvals Date issued: 09/06/2018 Current Use: Structure Permit Type: Building-Tent-Non-Profit Expiration Date: 03/06/2019 Foundation: Location: 2135 MEETINGHOUSE WAY/RTE 149,WEST y Map-/Lot: 130-012 _- W Zoning District: RF Sheathing: Owner on Record: BARNSTABLE,TOWN OF(LB) Contractor Name, Framing: 1 Address: 367 MAIN STREET Contractor License: i 2 m..,,__- HYANNIS,MA 02601 Est: Project Cost: $0.00 Chimney: Description: 40x40 tent no sides up 8/16 down 8/20 no food silent auction ` Permit Fee: $25.00 ( Insulation: Fee Paid`.( $25.00 Project Review Req: Approved with no sides 3104.12 Fire extinguisher,must be € t'intent 3104.E No Smoking signs Shall be posted Date: 9/6/2018 Final: Plumbing/Gas .,, Rough Plumbing: Building Official Final Plumbing: Rough Gas: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months-after issuance. All work authorized by this permit shall conform to the approved appl cation and the�approved construction documents for which this permit has been granted. Final Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. This permit shall be displayed in a location clearly visible from access street or roadand shall be maintained op errfor public inspectn for the entire duration of the Electrical work until the completion of the same. Service: The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided onthis permit. Minimum of Five Call Inspections Required for All Construction Work: m �4_,,. 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. Final: Work shall not proceed until the Inspector has approved the various stages of construction. Fire Department "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final: Building plans are to be available on site All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT APPLICATION NUMBER *For Tents Only* _7:1 Date Tent (s) will be erected Removed on b number of tents total Does the tent have sides? Yes No 1/ (If yes pie se attach floor plan with exits marked) Dimensions of each TentX X X Additional tent dimensions can be a ached on a separate piece of paper. Purpose of Event ' Q (, Check one: this event is a: for profit non-profit event Check one: Food served Yes Je 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. I 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 ?)IQ Ile All permit applications are subject to a building official's approval prior to issuance. 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): `�j TA-Ali ki Address: Joaa City/State/Zip: `,*bon #: Are you an employer?Check the appropriate box: Type of project(required): L❑ 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.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' [No workers' comp. insurance _ co . . ance. x 9. ❑Building addition required.] 5. a 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 12.1--1 Roof repairs insurance required.]t c. 152, §1(4),and we have no , employees. [No workers' 13.[j]<tther 6. comp. insurance required.] 'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. . I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under thepains and penalties of perjury that the information provided above is true and correct. Si mature: Date: / Phone#: J 3 �' ".2—3 S� 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 appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their 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 0211.1 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax# 617-727-7749 www.mass.gov/dia l 07/15/2010 12:08 812-867-0547 ANCHOR IND PAGE 02/04 cuj IMPORTANT DOCUMENT Certificate of Tlame Ssistance Date of Shipment ('k)i L.CU 0 ISSUED BY 07/07/10 Registration Number A CHOR®INDUSTRIES INC.. Tent Identification F140.1 14877530 EVANSVILLE,INDIANA 47725 MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN This is to certify that the materials described have been flame-retardant treated (or are inhe-ently noninflammable) and were supplied to: BARNSTABLE COUNTY CORRECTIONAL FACILITY 6000 SHERIFF'S PLACE BOURNE, MA 02532 ,r . ♦5 -� OF CALF q � F RE N► V R E't p Certification is hereby made that: The articles described on this Certificate have been treated with a flame-retardant approved chemical and that the application of said chemical was done in conformance with California Fire Marshall Code. All fabric has been tested and passes NFPA 701, CPAI 84. Serial# 8108985(1) Description of item certified: CENTURY MATE EXPANDABLE END 40WX20 SNYDER WHITE VINYL Flame Retardant Process Used Will Not Be Removed By Washing And Is Effective For The Life Of The Fabric SNYDER MFG NEVI/PHILADELPHIA.OH Name of Applicator of Flame Resistant Finish Signed: �-��� ANCHOR INDUSTRIES INC r pia„� r�w ��lhy I GeE�n/ Hour e� Town of Barnstable _ Building i Post This Card So That it is Visible From the Street-Approved Plans Must be Retained,on:job and this Card'Must be Kept 1' )Posted Until Final Inspection Has Been Made 639. Permit t• Where a Certificate of Occupancy is Required,'such Building shalLNotxbe Occupied until a Final Inspection has been made. Permit Permit No. B-16-3137 Applicant Name: FRANK A ZIBUTIS Approvals Date Issued: 10/31/2016 Current Use: Structure Permit Type: Building-Alteration INTERIOR Work Only- Expiration Date: 04/30/2017 Foundation: Commercial _ Map/Lot: 130-012 Zoning District: RF Sheathing: Location: 2135 MEETINGHOUSE WAY/RTE 149,WEST Contractor me: FRANK A ZIBUTIS Framing: 1 Owner on Record: BARNSTABLE,TOWN OF(LB) Contractor License�CS-052139 2 Address: 367 MAIN STREET rc Est. Project Cost: $5,000.00 Chimney: HYANNIS, MA 02601 s Permit Fee: $ 160.00 Description: remodel bathroom replace/repair framing as,needed - Insulation: Fee Paid,. $ 160.00 1. Final: Project Review Req: remodel bathroom replace/repair framing as needed Date- r 10/31/2016 Plumbing/Gas Rough Plumbing: ~--- ,, \tBuilding Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. All work authorized by this permit shall conform to the approved application and.theapproved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for:public inspection for the entire duration of the Final Gas: work until the completion of the same. I } Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Service: Minimum of Five Call Inspections Required for All Construction Work: 1.Foundation or Footing _. --- "�� Rough: 2.Sheathing Inspection - 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map l 3 0 Parcel Q 12 Application # .. 3� 3 Health Division Date Issued /D 3/. /6 Rock Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address �- 3 ,v�I _k61X e_ Village Owner `_yJ yy Address `3 (7 /Y6r,, 54- 14y�nv�-s N,+Ozer Telephone ---C 3 Z.0 Permit Request I Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation S,o 0o,C:d Construction Type Lot Size Grandfathered: ❑Yes 0 No If yes, attach supporting documentation. Dwelling Type: Single Family .0 Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: 0 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 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 0 new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing 0 new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization 0 Appeal # Recorded ❑ Commercial 0 Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name k Z C,�U: 'k S Telephone Number Address / ?d / cvs L Qn e-, License# .- IOX14 O ZG Home Improvement Contractor# Email Worker's Compensation # ALL CONSTRUCTION DEBRIS SULTI ROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 16h CJ z,6 i FOR OFFICIAL USE ONLY APPLICATION # " '< [DATE ISSUED ' } MAP/PARCEL NO. ' ADDRESS { VILLAGE " ti OWNER DATE OF INSPECTION: FOUNDATION FRAME 1 INSULATION FIREPLACE _ .r j ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING - �r - YS If DATE CLOSED OUT" ASSOCIATION PLAN NO. o�TME Tom, Town of Barnstable Administrative Services HARNSTABLE, Procurement&Risk Management ss BARNSTABLE y ma 230 South Street,Hyannis,MA 02601 suslf•a rn xravwt.cqr •xuatl i6S9• �0 www.town.bastable.ma.us vnn xswxsxus•nsremue•x;e+rsusE Ar�O..A�A I6J'J•2014 David W.Anthony Tel 509-8624652 Director of Property and Risk Management Fax 508-962-4799 David.Rnthony@tmvn.b.grnstable.ma.us I February 1, 2016 Town of Barnstable Building Department 200 Main Street Hyannis Ma,02601 I Ref: Town of Barnstable Workman's Compensation Coverage The Town of Barnstable commencing on July 2011,chose to enter into a certified Self Insured Workman's Compensation program. Instead of purchasing a policy with an insurance company as is the traditional method,the Town self funds a trust fund and pays for the lost wages, salaries and settlements out of this trust fund.For the 2015—2016 fiscal year,the Town remains self-insured. To manage the claims review and provide technical control of the program we contract with a certified third party administrator—TD North InsurancelUSI. The coverage of our employees for injuries suffered while at work is.through this program and if you have any further questions,please contact me directly. Sincerely,' David W. Anthony Director of Property and Risk agement Town of Barnstable n Oyx r -,a•..A)CA LN -41 CL � "O1 t m G1 _`k�'' � i•,,�' yl_ram, 1 Q "' i 163* Town of Barnstable Regulatory Services Richard V.Scali,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 5.08-790-6230 Property Owner Must Complete and Sign This Section. If Using A Builder I sTEPsfG—i� ,s�i ri�F� ,as Owner of the subject property hereby authorize �a w� i1owT�S to act on my behalf, in all matters relative to work authorized by this building permit application for: A�ese cola,. pkr 9 (Address of Job) Sign e o et T�✓�f�F.tJ J ��/E//7�G .z-CJ Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. Q:\W MESTORMSUilding permit formskE)TRESS.doc Revised 040215 Town of Barnstable Building Post This Card So That it is Visible From the Street-Approved Plans Must,be Retained on Job and this Card Must be Kept . RARM . """A p Posted Until Final Inspection Has Been Made.' Permit f6gp. �6' Jl Jlll 1. cud' Where a Certificate.of Occupancy is Required,such Building shall Not be Occupied until a Final Inspection has been made. Permit No. B-16-1009 Applicant Name: Menezio Louzada Map/Lot: 130-012 Date Issued: 05/13/2016 Current Use: Zoning District: RF Permit Type: Siding/Windows/Roof/Doors Expiration Date: 11/13/2016 Contractor Name: MENEZIO LOUZADA Location: 2135M EETI NG HOUSE WAY/RTE 149,WEST BARNSTABLE__ _ _-Est. Project Cost: $59,480.00 Contractor License: CS-094477 Owner on Record: BARNSTABLE,TOWN OF(LB) I Permit Fee: ''� $160.00 Address: 367 MAIN STREET } Fee Paid: ""$ 160.00 HYANNIS, MA 02601 �" Dater 5/13/2016 4 Description: One door and window replacement and other doors and windows scrape and repaint. F Project Review Req : ,. r' r t Building Official This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. All work authorized by this permit shall conform to the approved application and 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-law`s and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. The Certificate of Occupancy will not be issued until all applicable sign}Lures by the Building and Fire Officials are proLed on this permit. j Minimum of Five Call Inspections Required for All Construction Work: 1.Foundation or Footing I f 2.Sheathing Inspection t� 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 5.Prior to Covering Structural Members(Frame Inspection) I 6.Insulation 7.Final Inspection before Occupancy 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. "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Building plans are to be available on site All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT � !1 R ,tt•l �� � 1 /� .1'l ��.�::.: >• {{{rr �rr5�ir j f:� n ti�'-4 n'R' ^aft � J_\i yEt y^ { - _. .ti' / � a� Fad- •� i" .l,; •�.!\� 1�i �.Z.S y• '�' �-i"z 1_L < <'�tRj l "l R.. .�' - - ti. �. .ram- ^_ �_ - t M�l •�1 a.+f.M. _ .. -�� N .l 16 20", d.1:W:IrXd.:7 dt a Town of Barnstable Regulatory Services >u►RPrB[ABt�. ; Thomas F.Geiler,Director t 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 Property Owner Must Complete and Sign This Section If Using A Builder ////�/-` , as Owner of the subject Property hereby authorize Nagle Eyes Contractor's to act on my behalf, in all matters relative to work authorized by this building permit. Paine Black;House, 2135 Meetinghouse Way (Address of Job) 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. Signatur of Ow r igr lure of Pani� Print Name Print N e Date OAVertical Construction\ACTIVE PROJECTSTAINE BLACK HOUSE UPGRADES\Paine Black Windows&Doors\Contract\Owners Permission Form Building Permit-EagleEyes.doc ACOKt�° CERTIFICATE OF LIABILITY INSURANCE F DATE(MM/DDIYYYY) 1 04/19/2016 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 be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Christen Clery TONRY INSURANCE GROUP INC. PHON o �. (617)773-9200 1C No: ADDRESS: cciery@tonry.com ton com ADDRESS: 300 Congress Street INSURERS AFFORDING COVERAGE NAIC# Quincy MA 02169 INSURERA: TRAVELERS PROPERTY CAS CO OF AM 25674 INSURED INSURER B: EAGLE EYES CONTRACTOR INC INSURERC: INSURER D: 366 RIVERSIDE AVE 2 INSURER E: MEDFORD MA 02155 INSURER F: COVERAGES CERTIFICATE NUMBER: 45936 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLPOLICY NUMBER MM DI EXP DY EFF MM DD LIMITS LTR ' COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ DAMAGETO RENTED CLAIMS-MADE OCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑jE OT LOC PRODUCTS-COMP/OP AGG $ OTHER: $ AUTOMOBILE LIABILITY MBINED SINGLE LIMIT EaCO accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X STATUTE ERH AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $ 500,000 A OFFICERIMEMBEREXCLUDED? NIA NIA N/A 7PJUB2E33467315 07/15/2015 07/15/2016 (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I$ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwdtworkers-compensationAnvestigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Barnstable Town Hall ACCORDANCE WITH THE POLICY PROVISIONS. 367 Main Street i AUTHORIZED REPRESENTATIVE � -. r n tie7ry. Hyannis MA 02601 DaniFl tat.Crsr. !y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD ACORO® 7419/2016 (MM/DD/YYYY) ACC- CERTIFICATE OF LIABILITY INSURANCE 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 be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT PattyJensen NAME: Tonry Insurance Group, Inc. PHC N (781)861-1800 FAX NO:(781)861-1806 238 Bedford Street EDORESS:certs@tonry.com INSURERS AFFORDING COVERAGE NAIC# Lexington MA 02420 INSURERAI$ain Street America Assurance 29939 INSURED INSURERB:Citation Insurance Company 40274 Eagle Eyes Contractor, Inc. INSURERC: 366 Riverside Ave. #2 INSURERD: INSURER E: Medford MA 02155 INSURER F: COVERAGES CERTIFICATE NUMBER-CL163912648 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MMIDDIYYYY MM/DD/YYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO Ft A CLAIMS-MADE ❑X OCCUR PREMISES Ea occu ence $ 500,000 MPT0292W 3/11/2016 3/11/2017 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY JET LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY (CEO accidentMBINED SINGLE LIMIT $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ B ALL OWNED SCHEDULED AUTOS XM AUTOS LJ2031 12/5/2015 12/5/2016 BODILY INJURY(Per accident) $ X HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ a yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Certificate Holder is an Additional Insured, when required by written contract, but only to the extent provided in the Additional Insured endorsement(s) attached to the policy, a copy of which is available upon request. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Barnstable Town Hall THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 367 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis, MA 02601 AUTHORIZED REPRESENTATIVE L Tonry Jr./PATTYJ """ 7"� ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INSn25/gmanti TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel 11l ,�,��r v� roc Application �6 Health Division Date Issued 1 Conservation Division Application Fee0(;K ` Planning Dept. Permit Fee Date Definitive Plan Approved,by Planning Board Historic - OKH _ Preservation/ Hyannis GPI' l W_ io L� �1/ �N� Project Street Address � -� �f�e I Village Owner 1Nit,V±. ' A.Q T&M Address ..17135' yx Telephone Permit Request 4vua- Llv"e4& 466R. , Wxr,-c'Nn FX!gj r 0000S -AA*W_' peon.._ +n- , A&I ic�csocQ s cQ,o�n.{r iP-4 , �IOSF�/ � �Ti�s� s Q.�ri/ ,�o�+iQ �sTiNJ AM L"cP-P 2, uaaF F OP Rdd tuovh 4d-4 0�-5,v Square feet: 1 st floor: existing 11V proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Prlj luation -Ncua�ti onstruction Type IbOmQ vlveko Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure ? Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: 3 Full V ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) - Basement Unfinished Area(sq.ft) ��(o Number of Baths: Full: existing ne Half: existing— new Number of Bedrooms: existin — Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other NCL4tC 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: �jQdcc Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use nowt Proposed Use � vl APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name �' �`� p Tele hone Numbers `>Z� Address 10 G1JA&_P;t45 - License # Home Improvement Contractor# Email 4-04'_ egg-wiGd�At�T Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 01 I� FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED MAP/PARCEL NO. . ADDRESS VILLAGE OWNER C DATE OF INSPECTION: FOUNDATION FRAME t INSULATION FIREPLACE I I;ELECTRICAL: ROUGH FINAL ;S PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN.NO. s i �t Town of Barnstable Regulatory Services BAWM"ate' Richard V.Scali,Director Building Division 7V� Tom Perry,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 If Using A Builder I, David Anthony, Director of Property and Risk Management, as Property Manager for the Town of Barnstable, who is the owner of the subject property, hereby authorize, Judith Desrochers, Meetinghouse Farm Inc. to act on the my behalf on all matters relative to the work authorized by this building permit application for 2135 Meetinghouse Way, West Barnstable MA **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 Dlhvio W 67 Print Name Print Name. 10 Date A r or. i THE . . + BARNSrABM 9� 1D6J¢ � Town of Barnstable Regulatory Services Richard V.Scali,Director Building Division Thomas Perry,CBO 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. If Using A Builder I 1/ l"''�`-" `'� , as Owner of the subject property hereby authorize I GfI-P 6PA- 5a-ze--k' L to act on my behalf in all matters relative to work authorized by this building permit application for: (Address of b) Sig4nature of Owner ' Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. I ' QAWPFILES\FORMS\building permit formsNMRESS.doc Revised 040215 1 i 0 o a d� Mr ti a � U-1-11 3 4 . 3 f - Li �a a _- So �fi . r i I ti d Y) kb SI � dEa� VJ +i /!.0 fQCLI/U//EIYIECIIC(/./�Q•U(�IEQICEC�/ldC�,lA �. �{ License or registration valid for indmdul use only � �. Office of Consume[Affairs&Business Regulapon f c, d C E5ME.111APROVEMENT CONTRACTOR be the expifrat�on date if found returq toe ii,; rui 3.; egistretion Type:' Office ofCotisumer Affairs itntl. (tsiness°Regulation 109470:. a .. ,Expirati6n: 9/16/2016 DBA 10 Park Plaza'=Suite•S1'70 ' Boston,MA 02116 RANDALL G SWETISH BUILDERj?' �. RANDALL SWETISH. 10 WHEELER ROAD C tfMARSTONS MILLS, MA 02648 Undersecretary 4 Not valid w thout signature w r= Massachusetts Department of Public Safety lug Board of Building Regulations and Standards License: CS-010219 =" Construction-Supervisor ^sue: RANDALL G SWETISH .«.w 10 WHEELER RD MARSTONS MILLS MA 02648 �zu; Expiration: Commissioner 02/13/2018 � "^'�T�r—.-� - •..:Ra=-•:Ii•::L:...:..:� �'°rite. - - • Office of Consumer,,Affairs'&,Business Regulnhop License or registration valid for tndrvidul use-only , V: E)ME:111APROVEMENI CONTRACTOR..;;. before the expiiratton date i •found return tot .. �'► - egistration:=• �Og4�0 ; ''' Type: Office.of Consumer Alffat�sj tod uslness Regulation '! Expirati6n 9/16/2016:; DBA 1' 10 Park Plaza`-Suite 5170 Boston,MA 02116 RANDALL"G SWETISH BUILDER ;` RANDALL i 10 WHEELER ROAD yMARSTONS MILLS, MA 02648 Undersecretary i Not valid w thout signature Construction Supervisor Restricted to: Unrestricted-Buildings of any use group which contain less than 35,000 cubic feet(991 cubic meters),of enclosed space.' Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. DPS Licensing information visit: WWW.MASS.GOV/DPS 6 r ?lie Commonwealth of-Massadrusetts Deparofrerrt of rndaYtrial Acciderds Off-ce of fniw6gations. 600 Washington Street Bvston,CIA 02111 nn n1.:7na_,mgov1dia 'Workers' Campensatim Insurance Affidavit B•mlders/ContractorslEIecfricians/Plunbers Applicant Information Please Print Leagib ����st>s�ssror•�ani��al� ��� �cv�r�� A &ess: W lVX;Lb_n— R_k City/State/Zap -XkWX' s W8 Phone i J�k � �5�-24 Are you an employer?Check the appropriate Type of project r 4_ am a general contractor and I YPe p I � �: 1.❑ I am a employer with b 6- ❑ construction �loyees(full andl`or part-time)-* Have hired4 ie sub-contractors 2.4� lam a sole proprietor orpaitner- listed on.the attsched sheet 7. odeSing skip and have no employees. Ilese sub-contractors have g_ ❑Demolition working forme in any capacity_ employees andhave worl=' 9_ ❑Building addition [No�r,orkm'comp.insurance comp_insorance_1 a-corporation and its ed_ 5- ❑ We are 1�_❑Electrical repairs or a ddi rdons 3.❑ emir officers have exercised their I tint homeowner doing all work officers Flumbragrepairs or additions o ' right of exemption per MGL �'�£� workers �F- lry-❑Reofrepairs ,,nuance required.]i c_152, §ln andwe have no employees.[Novrorkers' 13.0Other 4&rr, AepAIA— comp.insurance required_I •Amy WHcsmfthst chedmbox r1 nmst also fiIIoutthe sectionbelaw showing ifieawofftexe campersatioupoycy iufbrmaiion_ #Homeowaecswbo submit¢his af5dnif inirs�' •g they are doing a1Fwa t and thenhire autsidecontxrctorsmust sm1amita newaffidarit indiating sud ICauimctom$ut check this box mast athched as additinmA shed slrowc hg themmn a of the sub-caatmaom and state*hether.or not those entitiesbare employees.If the sub-canttnctorshxve employeas,theymrtstpmvide-their=rkexs'camp.policy.number_ I aryl an eihp1gvr Mat is prauiding warken'compensrdion invirance,for my*employees $eToiv is fire pv1fcy arm joh site information �I Insurance Company Fame: l� Policy or Self-ins_Lic. L�-l� �"t I'o0—7y oLyS7O�0 2ylS'fr Expiration Date: Job Site-Address !36" ! CitylState z[p: �l1�tTj�l Attach a copy of the workers'compensationpolicy decI ration page-(showing the policy number and expiration date). Failure to secure cove nge as required.under Sectibn 2.5A o€MGL c-152 can lead to the imposition of criminal penalties of a fine up to$1,50U OO anNor one-yearimprisonmenk as well as civil penall es,in the form of a STOP WORK ORDERand a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of invesErgations of1he DIA for insurance coverage verification. I rfa hereby certi1fjv riatdRr the p art parr ' s a!f ' at Me informuti mpt,*Ted abm a is bue mid correct Sitstature_ li Date: l� Phone i�. Official use ore£y. Do not avrete in this area,tv be camplreted by cite ortomn official ; i City or Tanm.: FernutUcense# Issning An&ority(cirele one): L Board of Health 3.BuR Ting Department 3,CRyfrown Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#: ® YYY) M/DATE(MDD/Y Aa Ro CERTIFICATE OF LIABILITY INSURANCE DA TE(M /2015 DD/Y 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 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). op TT PRODUCER 00790-001 NAMEACT Frank L Horgan Insurance Agency Inc A/C.NNo.Ell): (508)775-5830 A/C No.: (508)775-6688 P 0 Box 250 EMAIL Hyannis,MA 02601 ADDRESS: INSURER(S)AFFORDING COVERAGE IC SURE • A.I.M.Mutual Insurance Company 33758 INSURED INSURER B Randall G Swetish R G Swetish Builder INSURER C 10 Wheeler Road INSURER D Marstons Mills, MA 02648 INSURER 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, gEXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN TYPE OF INSURANCE AOR N/VD POLICY NUMBER MM/DDY/YYFYY M0LLDDY/Yv P LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ occurrence) CLAIMS-MADE OCCUR MED EXP(Any one person) $ PREMISES fE. PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ EN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ ]POLICY ECO- OC AUTOMOBILE LIABILITY COMBINEeD SINGLE LIMIT $ ANY AUTO BODILY INJURY(Per person) $ ALL OW SCHEDULED BODILY INJURY(Per accident) $ AU OWNED TOS AUTOS HIRED AUTOS NON-OWNED PROPERTY DAMAGE $ AUTOS (Per ac id $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $ o DEDgg pp RETENTION $ yyc g 77UU 7H $ ANNyD ERMpPLRO�YEETRQ8��LIgAB7TLNIE.rf E YY�'NN X TORY LAMITS OER /\ OFFICERMIEMBER/EXCLUDED?ECUTIVEI�I N/A AWC-400-7024566-2015A 4/19/2015 4/19I2016 E.L.EACH ACCIDENT $ 100,000,00 (Mandatory In NH) u E.L.DISEASE-EA EMPLOYEE $ 100,000.00 D SsCRIPTION OnF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) t CERTIFICATE HOLDER CANCELLATION Town of Falmouth 59 Town Hall Square SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Falmouth,MA 02540 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. " AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD \ I TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map' � 3 o Parcel O/-Z a Application #� Health Division Date Issued 7i l Conservation Division s;�� W ek .��/rr/�v� Application Fee f Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board . 6W Historic - OKH _ Preservation/ Hyannis Project Street Address Village L �� ,4r.✓�rTx��E Owner Address 3 s is Telephone��j��; 9a— L72-0 Permit Request 2N.1721.LL n oU.2 - ,f/r ;�/'C72g' r Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay U) Project Valuation's Construction Type f OVO -�- Lot Size Grandfathered: ❑Yes ❑ No If yes, attach su porting`d'ocuntation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) v Age of Existing Structure Historic House: '1�Yes ❑ No On Old King' Highway,:;*X l�% ❑ No Basement Type: ❑ Full ❑ Crawl O'Walkout ❑ Other T 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 A1041,6_-� Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes J$ji No Detached garage:existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial )81 Yes ❑ No If yes, site plan review # N�i9 - Current Use - Proposed Use -�-- APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name yA0i 49vzo.✓ Telephone Number Address sh3 '&i�.� Lt qu License # �J-0 ;4 , /`9f ty2(h i Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO JJ�iV/_ Z/// SIGNATURE DATE FOR OFFICIAL USE ONLY a APPLICATION# DATE ISSUED t MAP/PARCEL NO. k,. ADDRESS ' VILLAGE r ` OWNER t DATE OF INSPECTION: wFO.UNDATIQNi�� t FRAME ' �lNSULATION .a t :_•t� ,; ::5��.t r� FIREPLACE ELECTRICAL:, , ROUGH - FINAL - t PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING.----. - - ' DATE CLOSED OUT, ASSOCIATION PLAN.NO. 77te Commonwealth of Massachusetts Deparhnent of Indiustrial Accidents Office of Investigations ' +600 Washington Street Boston,MA 02111 www.mass_goyldia Workers' Compensation Insurance Affidavit Builders/Contractors/ElectricianstPlumbers Applicant Information Please Print Legibly Name(B onau ividual): Ae`/A.z/ G4 yz 0. - Address: JAzy �✓I cat^ l.�/a u /J r/ �j p� City/State JJZ�: / 4,,, ;J g I 2�OQ Phone ik J "0p pO f— Are you an employer?Check the appropriate box: Type of project(required): 1.;i�I am a employer with 4. ❑ I am a general contractor and I 6- ❑New eonshuction employees(fall and/or pact-t me).* have hired the sub-czntssctois 2.❑ I am a.sole proprietor or partner- listed on the.attached sheet. ?- ❑Remodeling ship and have no employees These sub-contractors have g_ ❑Demolition working for me in any capacity. employees and have words' 9. ❑Building addition[No workers'comp.insurance, comp.insurance- 1 5. ❑ We are a corporation and its. 10.❑Electrical repairs or additions required-] officers have exercisedh teir 11. Plumbing 3.❑ I am a homeowner doing all work ❑ g 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 apphc=that checks box#1 nmst.also fill out the section below shoring their wodkers'compensation policy informatiab i Homeowners who submit this arfidava indicating they are doing aU wool and then hire oamde contractors mast submit a new of dsvit indicating such_ iContractors that check this WE must attached an additional sheet showing the name of the sub-eomnacors and state whether at not those entities have employees. if the nib-contactors;have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensdton insurance for my employees. Below is the policy and job site information. Insurance Company Name: rue z--D — Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: 1)/2J_ City/State/Z.ip:U/ 6A/e�_V�31.E 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 impositiom of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under tkepains and penalties ofpeejury that the information provided above is true and correct 2 Date' > c Sitmature �i_T��-Y-- ��� Phone# O,f"reeal use only. Do not write in this area,to be completed by city or town oJjiciaL City or Town: PermitUcense# Issuing Authority(circle one): 1.Board of Health 2.Binding Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone 9: 6 ti WiVlassachusetts -Department of Public Safety Board of-Building Regulations and Standards. Construction Supervisor License: CS-065007 \\\ .0 'BRYAN•E LAUZOf7 e 18 LAREVIEW ST PUBX�l2'S! S CARVER MA 02366 I J ,rn� Expiration Comrttissioner 08/23/2015 r °F r Town of Barnstable Regulatory Services MA sA I E Thomas F.Geiler,Director 16.19. & 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 Property Owner Must Complete and Sign This Section If Using A Builder 1, �%� ,(� T. s( 1/r/DFL i�) , as Owner of the subject property hereby authorize_ f!�✓ /.4 Uzov to act on my behalf, in all matters relative to work authorized by this building permit. (Address of Job) **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. Signa e o caner Signature of Applicant sTGp��Fi✓ 7- Print Name Print Name 3 Da e Q:FORMS:OWNERPERMISSIONPOOLS 6/2012 �1t4E, Town of Barnstable Regulatory Services ' '"L'ABI ' Thomas F.Geiler,Director 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 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 109.11-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. C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\ContenLOutlook\QRE6ZUBN\EXPRESS.doc Revised 053012 r Q Q J O � v . I \ v � � � I� �-, 0 x r � �� � � ''i � � � \. . --� � � , c �` ,� � 9 � � _ � TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Pp Parcel v K lication#��� Health Division Date Issued 10 Conservation Division Application Fee ` 2 Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board L Historic - OKH _ Preservation/ Hyannis Project.Street Wrvs n eef- g( -Village Owner_�u 1 K a Qayn sp 1L Address '3 Gi 7 _Telephone d 11K rr0 63 20 Permit Request -T-r-► rn ► J Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation s Construction Type �oe Lot Size Grandfathered: ❑Yes ❑ No If yes, attac,I j fupportipq documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Ell Age of Existing Structure Historic House: ❑Yes ❑ No On Old Kg's Highwpy: 0 Yes ❑ No Basement Type: ❑ Full ❑ Crawl EllWalkout ❑ Other NJ C :"o Basement Finished Area (sq.ft.) Basement Unfinished Area (Jq.ft) Number of Baths: Full: existing new Half: existing mew 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 ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name f2t, I/�- b [n� cam; 1 Telephone Number e-T& 32,Z CQ (T- Address v License # o31 G7/S l G Z 6 Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO 'SIGNATURE DATE 06 2 6 1 FOR OFFICIAL USE ONLY ! APPLICATION# DATE ISSUED MAP'/PARCEL NO. ADDRESS VILLAGE OWNER ?� DATE OF INSPECTION: ' - � FRAME R- INSULATION;LH. •_-�.,..- , .;��y 1 a. '} FIREPLACE ' ELECTRICAL::_ ROUGH FINAL PLUMBING: ROUGH FINAL GAS' ROUGH FINAL FINAL BUILDING", =�` r DATE CLOSED OUT ASSOCIATION PLAN NO. i The Commonwealth of Massachuseft 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): —EcI1yV &CL12�p3e Address: 3 _T v l ct n -<,:�ee c City/State/Zip: (/�( Phone#: d g— 2 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 hued the sub-contractors 6. El Now construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet 7. {]Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity.acit3'• employees and have workers' t 9. ❑Building addition [No workers'comp. insurance comp.insurance. 10. Electrical repairs or additions required.] 5. ❑ We are a corporation and its ❑ ep officers have exercised their 11. Plumb' repairs or additions 3.❑ I am a homeowner doing all work � P 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$omeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. xContractors 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: ' S yfZ 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 cerdfv under the gains and penalties of perjury that the information provided above is true and correct Si afore: `'C Date: Z� C Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: r oFtKJE> t 1ARNSTABI4 "�: ,.� Town of Barnstable �fD MP't A Regulatory Services Thomas F.Geiler,Director Building Division Thomas Perry,CBO 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 If Using.A Builder I. S+eu f= S L.VNA P l✓t , as Owner of the subject property hereby authorize l ro�v�� Z L�ti'�i S to act on my behalf, in all matters relative to work authorized by this building pertnit application for: CJz, Q,l�le a-(QsS� (Ad ess of Job) / Signa e o caner Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. C:\Users\decollik\AppDatakLocal\Microsoft\Windows\Tempos Intemet Files\Content.0utlook\ RE6ZUBN\EXPRESS.doc �Y Q Revised 053012 Massachus etts _:D' Board of 6 9 Re artment,of Pub.liF'Safet :' ,k uildin Constr 9ula}ions Y ,. •. uctiop and.SNnd..,.Supon`isr)r ards.�'.::'; License: CS-05213 r FIR UTT ANK A ZIB 130 RASpBERR , MARSTONS w . 8 Comm-issioner EXPiration .: 06/18,2015':' ra TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map O Parcel 6 Application # Q pflf"_� � Health Division Date Issued O Conservation Division Application Fee �o . Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/ Hyannis Project Street Address Village Owner `I���►I/l RC,..-n o3o le. Address 3 C-T Telephone -0 T 71:7 Q ( 3 2-0 Permit Request f C�ce ,e /� e 8 J I��iicfrl"�' !'oaT ShlrLJQs �t/e�J —Ila rJOWS Q. oafs a5 V1 eeJ ed .Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay .Project Valuation Id,AQ 4,CIO Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure /1G Historic House:' ❑Yes 0 No On Old King's Highway: Yes ❑ No Basement Type: ❑ Full ❑ Crawl XWalkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing n(:W --� Number of Bedrooms: existing _new cn f , o Ca 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 rr� Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing newn size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION l (BUILDER OR HOMEOWNER) Name Fe-cxi,,.k z,� T� Telephone Number "-i5_0'& `3-Zg r R I_1 Address /30 /Cc►.c n 6-ct-, I License # C) lair v,s U" S Home Improvement Contractor# Email Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO Case �q 14 0r M411 D ISern&We_ safj SIGNATURE - a, DATE 2 26 (`t P FOR OFFICIAL USE ONLY ' APPLICATION# DATE ISSUED, � s y MAP/PARCEL NO. " ADDRESS VILLAGE OWNER r, DATE OF INSPECTION: r . FOUNDATION FRAME INSULATION — � FIREPLACE 5 ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL i. GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASS9>CIAT,ION-PLAN NO. " t The Cons•wanytwalth of Massachusefts Deparment of hdratiial Accidents Ofilice of nvesi grrtions 600 Washington Street Boston,,MA 02111, www..-nasmgaiVdia Worlc�ers' Compensa€ionInsurancieAflidavit Builders/Contra:ctorslFAectricianMu-mbers Applicant Infarmatian Please Pant Legibly Name(Bo�ftwizafion&dividiaq_ f oW y, [- b2S1 0 s�� Aadrt. : 3 `� �`1a Sr City/State/Zip: a v1 h,ts Z O l Phone� TO g -710 G 3 ZO Are you an employer?theck the appropriate box: T of ect(required): 4. )"I am a goal contractor and l � e°� I.❑ I am a employes with ./ � 6_ New o�sfiuctoo; eroployees(full and/or part-time)* have hired the mb-con actors. I❑ I am a sole proprietor or partner- listed on the attached sheet 7- 0 Rem deliug ship and haze no employees These sub-contractors have 8- ❑Demolition working for me in any capacity employees and have workers' 9_ ❑Building addition [go workers' comp.,iuyarance comp.insurance regvired-] 5_❑ We are a corporation and its 1{}❑Electrical repairs or additions 3.❑ I am a homeawmrs dbing all work officers haute exercised their I I_.0 Plumbing repairs or additions. myself [No workers'comp_ right of emmption per MGL 12-2 Roof repairs insurance regpfi-e&]1 c_152, §1(4),and we have nn employees-[No workers' 13_❑other comp_msmwxn --reginred-j. *Any spplioat that checks box W 1 tmtst also fill oit the section beIoty chrtaing$teii woakea�compensation policy nnffirmdkm T Homeowners vrho submit this affidavit i„d cstarE they are doing s1T trmik and tfien hue oniside contractors mast submit a ueza alsdn7t mrTrsdm sarh_ 1tcactnrs that check this bmc m¢s7 stiacherl au additional sheet shoumg the name of the srf-colors and state whether ornot timsE awes liX99e Epluyees_ Ifthe sob-coatrsctorshare empIoyees,they must pmvide their workers'comp.policpn-nnber_ I am art omployer that is prmridrtg workers'con.gmuuu'Lan irmirartce for rrty emp ayeem Helots is the poEcy and}ob site iriformatian_ Insurance CompanyName: Policy#or Self-ins-Lim ut �a V\ Expiration Date: Job Sites Add-ere: z 131-ItLed, City/State/T4p: Attach a copy of the workers'compensatiom pa-,.Y declaration page(showing the policy number and expiration date). Failure to secure coverage as mquiredunder Section SA o€MGL c- 152 can Lead to the imposition ofcriminA 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 S250.00 a.day against the violator_ Be advised that a copy of this statement may be forwarded to-the Office of Inresfigations of the DIA far insarance coverage vacation_ I do hereby c7erhfy render the INdns andpenalfies ofperfury that the infornzedion primidsd above iss bwz and correct Bate: Phone#: ©fficial use onry. Do n-ot write in this area,to be coampleted by city or town o ciaL City or Town: PermitUcense if Issuing Antharity(circle oae). L Board of Health 2.Buffding Department ' CityffaKn Clerk 4.EIectrical Inspector 5.P'lumbing Inspector .6.Other Contact Person: Phone 9: 6 Information and. Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto 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 Iocal 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 auy 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." i I — 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 ceriificatc-(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(L LP)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 '11e 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 see 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 add-tion,an applicant that must submit multiple permit/license applications in any given year,need only submif 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 aflzdavit.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�.x number: neh Commaawealth of Massachusetts. Depazt=nt of Industrial Accidents Office of kvestigatims 600 Washington Street Bostou,MA G2111 D!J.A 617-727-49-00 w 406 or 1-9 MASSAFE Revised 4-24-07 Fix P 617-727-7-149 Qww.mas.5,govtldia • anaivsrAsLY. • � ' ,� Town of Barnstable AlEO PAp�A Regulatory Services Richard V.Scali,Director Building Division Thomas Perry,CBO 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 If Using A Builder 1, as Owner of the subject property hereby authorize 17,t-AwL Z �`ok to act on my behalf, . in all matters relative to work authorized by this building permit application for: (Address of Job) Signa of O er15ate Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. Q:\WPHLESTORMS\building permit forms\EXPRESS.doe Revised 061313 Massachusetts =•Department'of Pub.lic,Safetf:`.;` `Board of Building Regulations and:StandarcJsi '-, Construction Supervisor License: CS-052139 . /) FRANK A ZIBUT 130 RASPBERRliLAiTL ,.. MARSTONS MI�cLSM©V 02.48 Ex Commissioner . 06/18iM.5:; '-Unrestricted -Builduigs of any use group which. ' contain less than 35,000 cubic feet (991A, of enclosed space. + , Failure to possess a current edition of the Massachusetts. State Building Code is cause for revocation-of this license.'.. is 'FoFDPS Licensing information visit: www.Mass.Goy/DPS ., t t I OFFICE OF THE SHERIFF RAINSUBIE COUNTY ® The Con=onweaM Of Mjmachusetts v u PA 6000 Sheriff's Place,Bouriae,MA 02532 508.563.4300 Fay.508563.4574 DCSO@bshcriff nct ACCREDITED St® Igloos t CONIMIGOS August 8, 2014 FOUNDED 1870 A�me,acsu Thomas Perry, Building Commissioner Correctional TOWN OF BARNSTABLE Association 200 Main.Street Hyannis, MA 02601 Dear Mr. Perry: I have been asked to provide a letter regarding workers compensation coverage for inmates In the custody of the Barnstable County Sheriffs Office who are erecting CO Accreditation of and dismantlingtents for the Town of Barnstable. o �Lehabikit-ador� Facilities These inmates are not paid wages for the services that they perform. They are providing a community service. They are not employees as a matter of Massachusetts law. They are not covered by worker's compensation insurance nor are they eligible to receive such. The Barnstable County Sheriff's Office itself is self-insured for its employees, the Community Service Officers, for worker's compensation purposes. Therefore, the Sheriffs Office does not maintain a worker's compensation policy. As an entity of the Commonwealth of Massachusetts, the Sheriffs Office is self-insured for all purposes. Please feel free to contact me if you have any questions in this regard. Very truly yours, Matthew Murphy, Esquire Assistant Superintendent General Counsel /sdr Enclosures ffANXW BARNSTABLE-BOURNE-BREWSTER- CHATHAM-DENNIS -F.ASTHAM-FALMOUTH-HARWICH MASHPEE- ORLEANS -PROVINCETOWN- SAN)DWTCH-TRURO-WELLFLEET-YARMOUTH 4 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application Health Division Date Issued Conservation Division Application Fee -� Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address 5�7) M•e +ii qh aoaq - �.�YlJC �l&I.) 401a Village �,��5�L.�'�IS� �� Owner I ouw\ Address � a oZ3 Ll.rl n I , Telephone_ Permit Request j fi h ca J s - rA CedcLr Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain __ nn Groundwater Overlay Project Valuation d D� Construction Type ��l n Lot Size Grandfathered: ❑ ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: X Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑Crawl ❑Walkout ❑ Other -a Basement Finished Area (sq.ft.) Basement Unfinished Area (sq x= Number of Baths: Full: existing new Half: existing ®� new au Number of Bedrooms: existing _new cn Total Room Count (not including baths): existing new First Floor Roo Count- Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other ' rn 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 ❑ Commercial , ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) _ Name Telephone Number Address `1 I `(�V1P� License # Home Improvement Contractor# Email LUDi 60M4YUL&n.I m& Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO Z O� jCs`I SIGNATURE DATE_ FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED' b MAP]PARCEL NO. ; ADDRESS VILLAGE OWNER DATE OF INSPECTION: . T j FOUNDATION FRAME INSULATION — ` FIREPLACE is ELECTRICAL: ROUGH FINAL— ' PLUMBING: ROUGH FINAL — G'AS: ROUGH FINAL FINAL, BUILDING r • DATE CLOSED OUT j ti ASSOCIATION-PLAN NO. y a r . ... .... .... y w 27w CommomwaMi ofMassachusdYs Deparwent of Iar huft d Accidents Q,we of, In ves4aYions 600 Mayhingtort Street. Boston,MA 02JII wnw ina-mgmMia Workers' Compensation Insurance Affidavit:Builders/Conhmctors/FAectriciansMumbers Applicant Information Please Prnaf Legibly N..(a 0,i.t- n&iW: 1,00 (LT n-h �Dn d-I Tad Your ►�'� Cityl tat&Zip: ; �c,Y ,M Phone 4- 5bg) ( 1 Z——3 1 q-7 Are you an employer:'Check appropriate bo= T of project (r 4. Iat�ia contractosaud'I � (���- I am a employer with � 6- ❑New cmstruc#oit [- employees(full andlor part-time)* have hired the sub-contractors listed on the attached sheet y- ❑Remodeling Z,_El I am a sole proprietor or partner- These sub-oonractors have sbip and have no employees f g- ❑Denwlitsoa w :Eor me m ask cap-city�- employees and have workers' working y cape t3 $ 4_ ❑Building addition Wo Workers, comp.insurance comp.♦nsurar required-1 5_❑ We are a corporation and its 10.0 Electrical repairs or additions ❑Plumbing their officers n-,e exercised 11_. airs or additions I❑ I am a hAm�vcner doing all wark h g� myself [No workers'comp- right.of P\�.fionper MGL 12-rR,,f negaas insurance required.]I c-1.52,§1(4) and we have no employees-[No workers' 13- Other comp-insurance rt gtnred-1 *Any anpH�at that chedzs boat*1 trmst also fill out thQ section below showing Their woxIceme compensation goiicy infest on Homeowners vrhfl submit this atbdavif indicsting they are doing rrutic anal then hug otdside contracture nmu3 submit a m-w afdsrit mffiraf l sack tcautiscrurs that check this bmc mast zmched an additional sheet showing the m®e of die sob-cnrdrsctvrs and state vrhedw oe not those om ities ILA aW layees. If the sub-contractan hwe empIasee_%they nnut pruvide their tearkers'comp policy number_ I am am empZayer ihat is pro•► tt orkers'c-ongmnsntion imrttraace for mar elrtp7nyem BeZoty is the pQ&y and job sits informalian_ Insurance Compairy'Plame: f Policy�or Self-ins-Lim (L1t?) b L /�I c� 1 l Expiration Date: 6 lolho Job Site Address: 41 ) Cit-,,MateJZip: Attach a copy of the workers'campeu' policy declare on page(showing the policy number and expiration date). Failure to secure co-verage 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 andlor one year imprisonme&,as well as civil penalties i a the fame of a STOP WORK ORDER-and a fine of up to$250-DO a.day against the violator- Be advised that a copy of this statement may be fGrwarded to the Office of lmrestiptions of the DTA for insurance coverage verbcation_ I do hereby aerft;fy ander the pains and penalties ofpedwy that the information prmzded abrrue is bue and correct Phme 9: 65 ©f,Eciol use on[y. Da not write in this area,tv be completed by city ar town official City or Town: PerrmtUcense# Issuing Authority(circle one)-. 1.Board of Health 2.Building Department I Citytrown Clerk 4_Electrical Inspector 5.Plumbing inspector .6.Other Contact Person: Phone 9-. 6 Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuautto 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 Iocal licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth;or 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 perbormance 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 amd,if necessary,supply sub-contractors)name(s), address(es)and phone number(s) along with their certificaie(s) of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(L LP)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 Depa-z�ent of industi-ial Accidents for confirmation of insurance coverage. Also be sure to sign and date the ai fidavnt 'I1ne 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. Sell 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 t_he applicant Please be sure to fill in the permit/license number which-AU be used as a reference number. In addiiicn,an applicant that must submit multiple permitlliu mse 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 he applicant as proof that a valid affidavit is on file for future permits or licenses. Anew affidavit must be Llled 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 aftidaN-it. 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 GomrcLQnvw�ealth of 1�Iassaehusetfs Department of Industrial Accidents Qffee of kvest gatioas 600 Waswnaton Stzt-e-'t Boston,IAA 02111 TO.,A 617-727-49-00 ext 406 or 1-&77-I ASSAFE Revised 4-24-07 Fax 9 617-727-7749 Www.roass.govldia A6Lo CERTIFICATE OF LIABILITY INSURANCE u;TOE8-2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: OXFORD INS AGCY INC PHONE FAX 300 MAIN ST "C.No Ext: ('C, No): OXFORD,MA 01540 E-MAIL INSURER(S)AFFORDING COVERAGE NAIC S INSURER A:THE TRAVELERS INDEMNITY COMPANY OF AMER! INSURED INSURER B: W P I CONSTRUCTION INC INSURER C: 4 TANNER ROAD WEBSTER,MA 01570 INSURER D: INSURER E: INSURER F: COVERAGES THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADD SUB POLICY EFF POLICY EXP LTR INSR WVD POLICY NUMBER MM/DD MM/pp LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ PREMISES Ea occurrence CLAIMS-MADE❑ OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY JEC7 LOC $ AUTOMOBILE LIABILITY MBINED SINGLE LIMIT $ a acadent ANY AUTO DULED ALL OWNED SCH BODILY INJURY(Per person) $ E AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON-OWNED OPERTY AUTOS AMAGE $ $ UMBRELLA UAB I OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I RETENTION$ $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY / TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIV N/A E.L.EACH ACCIDENT $100,000 OFFICERIMEMBER EXCLUDED? Y 6HUB 01-01-2015 01-01-2016 (Mandatory in NH) 9901 L942 E.L.DISEASE-EA EMPLOYEE $100,000 It yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,It more space Is required) CER11FICATE HOLDER CANCELLATION TOWN OF BARNSTABLE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE 230 SOUTH ST CANCELLED BEFORE THE EXPIRATION DATE THEREOF, HYANNIS,MA02601 NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE �l ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD t Massachusetts-Department of Public Safety Regulations and Standards Board of Building Construction Ss?61i46r License: CS-0�,, rr �' W p,1CIECH J PIV� . • s 4 Tanner Road Webster)" 01579 Expiration 0110212016 Commissioner he U.'o�urrrnrrttrcvrll�%Q�I�aJ.rrrc�r%te//f ffice of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR Type- IF- U9606 private Corporatior piration: 112612016 WPI CONSTRUCTION INC WOJCIECH PIWOWARCZYK �- 4 TANNER ROAD ; WEBSTER,MA W5/0 Undersecretary Mass. Corporations, external master page Page 1 of 2 � f William Francis Galvin Secretary of the Commonwealth of Massachusetts S k 1 Corporations Division Business Entity Summary ID Number: 010551762 Request certificate I New search Summary for: W P I CONSTRUCTION, INC. The exact name of the Domestic Profit Corporation: W P I CONSTRUCTION, INC. Entity type: Domestic Profit Corporation Identification Number: 010551762 Date of Organization in Massachusetts: 09-07-2005 Last date certain: Current Fiscal Month/Day: 12/31 The location of the Principal Office: Address: 4 TANNER RD City or town, State, Zip code, WEBSTER, MA 01570-2123 USA Country: The name and address of the Registered Agent: Name: STANLEY M. GOLENIA Address: 699 WASHINGTON STREET City or town, State, Zip code, SOUTH ATTLEBORO, MA 02703 USA Country: The Officers and Directors of the Corporation: Title Individual Name Address PRESIDENT WOJCIECH PIWOWARCZYK 4 TANNER ROAD WEBSTER, MA 01570 USA PRESIDENT WOJCIECH PIWOWARCZYK 4 TANNER RD WEBSTER, MA 01570-2123 USA TREASURER WOJCIECH PIWOWARCZYK 4 TANNER ROAD WEBSTER, MA 01570 USA SECRETARY WOJCIECH PIWOWARCZYK 4 TANNER ROAD WEBSTER, MA 01570 USA VICE PRESIDENT WOJCIECH PIWOWARCZYK 4 TANNER ROAD WEBSTER, MA 01570 USA http://corp.sec.state.ma.us/CorpWeb/CorpSearch/CorpSummary.aspx?FEIN=O 10551762... 12/22/2014 01/13/2015 13:08 FAX 5089437771 WPI CONSTRUCTION Z 001 El OWNER-CONTRACTOR AGREEMENT FORM TOWN OF BARNSTABLE,MASSACHUSETTS AGREEMENT BETWEEN CONTRACTOR AND TOWN OF BARNSTABLE THIS AGREEMENT,made this ^ day of / "eE'iyJl / 2014 by and between the TOWN OF. BARNSTABLE, Massachusetts, hereinafter called Owner, and WPI CONSTRUCTION, INC., with legal address and principal place of business at 4 Tanner Road,Webster, Massachusetts 01570 hereinafter called Contractor. WITNESSETH: That for and in Consideration of the payments and agreements hereinafter mentioned, to be made and performed by the TOWN OF BARNSTABLE, the CONTRACTOR hereby agrees with the TOWN OF BARNSTABLE to commence and complete the Paine Black House And Burgess House Roof Replacement Project hereinafter called the Project, for the consideration set forth in the Proposal and all extra work in connection therewith, under the terms as stated in the General and Supplemental General Conditions of the Contract; and at their own proper cost and expense to furnish all the materials supplies, machinery, equipment, tools, superintending, labor, insurance, and other accessories and services necessary to complete said Project in accordance with the conditions and prices stated in the bid submittal dated November 2, 2014 and the Construction Specificationstinvitation for bid dated October 7,2014 including Addendum 1 thereto, all of'which are made a part hereof and collectively evidence and constitute the Contract_ Work Schedule - Work shall be substantially completed by January 1, 2015. Construction may begin upon Notice to Proceed_ Contract Value—Eighty One Thousand Seven Hundred Dollars($81,700.00) Note; Pricing includes 128 square feet of 518" Plywood Sheathing at$5.50 per square foot. Contractor shall be paid for the actual amount of sheathing requirement for this project. Force MaLeure - The Contract shall be subject to Force Majeure considerations. Either party hereto shall be excused for performance of any act under the contract if prevented from performance of any act required by reasons of strikes, lockouts, labor trouble, inability to procure materials, failure of power, fire, winds, Acts of God, riots, insurrections, war or other reason of a like nature not reasonable within the control of the party. The period for the performance of such obligation shall be extended for an equivalent period for no additional cost to the Owner_ Continued failure to perform for periods aggregating sixty (60) or more days, even for causes beyond the control of the Contractor,.shall be deemed to render performance impossible, and the Owner shall thereafter have the right to terminate this agreement in accordance with the provisions of the section entitled "Termination of Contract"_ Termination of Coitra_ct - Subject to the provisions of the section explaining Force Maieure, if the Contractor shall fail to fulfill in a timely and satisfactory manner its obligations under this agreement, or if the Contractor shall violate any of the covenants, conditions, or stipulations of this agreement, which failure or- violation shall continue for seven (7) business days after written notice of such failure or violation is received by the contractor,then the municipality shall thereupon have the right to terminate this agreement by giving written notice to the contractor of such termination and specifying the effective date thereof, at least seven (7) days before the effective date of such termination_ Insurance -The Contractor shall maintain insurance with minimum limits as defined in the General Conditions, Article 14, for the entire duration of the project work to be performed, and provide a certificate of insurance with the Town of Barnstable named as an additional insured. Renewal certificates of insurance must be submitted to the Town of Barnstable, Risk Management, 230 South St., Hyannis, MA 02601 on a yearly basis. Governing Law—This contract Is governed by the laws of the Commonwealth of Massachusetts- 2 01/13/2015 13:09 FAX 5089437771 RTI CONSTRUCTION 002 Massachusetts General Law Chapter 149 hereby applies to this contract. Prevailing Wage Rates dated 10/6114 apply to this contract. The contractor shall submit weekly certified payrolls with invoices to Town of Barnstable. Attn: John Juros, Town of Barnstable, Structures&Grounds, 800 Pitchers Way, Hyannis, MA 02601. OS HA 10 certification required for all employees and subcontractors performing work on the job site_ A one hundred(100%)payment and performance bond is required with the signed contract. The Contractor shall indemnify, defend, and save harmless the Town, all of the Town officers, agents and employees from and against all suits and claims of liability of every name and nature, including attorney's fees and costs of defending any action or claim, for or on account of any claim, loss, liability or injuries to persons or damage to property of the Town or any person,firm,corporation or association arising out of or resulting from any act, omission, or negligence of the Contractor, subcontractors and their agents or employees in the performance of the work covered by this Agreement and/or their failure to comply with terms and conditions of this Agreement . The foregoing provisions shall not be deemed to be released,waived or modified in any respect by reason of any surety or insurance provided by the under contract with the Town. THE TOWN OF BARNSTABLE agrees to.pay the Contractor for the performance of the Contract, subject to additions and deductions, as provided in the General Conditions of the Contract, arid to make payments on account thereof as provided in Article 1 MEASUREMENT AND PAYMENT of the Special Conditions. The total payment shall not exceed this contract amount of$81,700.00, without the written authorization of the Town of Barnstable. By' WPI Construction, Inc. Approved to form; r Rut J. eil,Town Attorney Wojci c Piwowarczyk, President �. By_ TOWN OF BARNSTABLE Lynch,To anager I hereby certify that the Town of Barnstable has an appropriation to cover the cost of this contract in accordance with Ch 44§31C of the Massachusetts General Laws. By; Mark Milne, Finance Director 3 i r 01/13/2015 13:09 FAX 5089437771 WPI CONSTRUCTION [>3J003 J SIGNATORY AUTHORITY— Paine Black House and Burgess House Roof Replacement Project At a duly constituted meeting of N held on !i f Name of(Corporation) at which all Directors were present or waived notice,it was voted that: (Name) (Officer) of this company,be and he/she is hereby authorized to execute contracts and bonds in the name and ` behalf of said company, and affix its Corporate Seal thereto,and such execution of any contract or obligatio in this company's name on its behalf of such under seal,of the company,shall (Officer) be valid and binding upon this company. A TRUE COPY, ATTEST: (Clerk) _ Place of Business: 1 � - g' Date of this Contract: I hereby certify that I am the clerk of the W P GK �KC that i�c1'�f PL11 �I INuva rc is duly elected r( of said company,and the bove -- - vote:has not been amended or rescinded and remains in full force and effect as - - - of the date of this contract (Clerk) . (CORPORATE SEAL) On this day of r/ , 2014, before me, the undersigned notary public, personally �C' ,�, proved to me through satisfactory evidence of appeared 2 identification;w 'c e �. to be person ose name ed on the preceding or a ed docu_m/en in my presence. Not u tc jG, /� o on expires: IF A CORPORATION,COMPLETE ABOVE OR ATTACH TO EACH SIGNED COPY OF THE CONTRACT A NOTARIZED COPY OF VOTE OF CORPORATION AUTHORIZING THE SIGNATORY TO SIGN THIS CONTRACT. IF ATTESTING CLERK IS THE SAME PERSON AS THE INDIVIDUAL EXECUTING THIS CONTRACT, HAVE SIGNATURE NOTARIZED ABOVE_• KIMBERLY A. RZEZNIKIEWICZ Notary Public Commonwealth of Massachusetts 4 �j My C;,ommiesion Expires October 15,2015 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 1' Parcel Application # � D Health Division Date Issued 4. Conservation Division Application Fee Z60 Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/ Hyannis Project Street Address Village Owner "7'�c�-� !�� �jGc�2�+.c6��6 Address ? Telephone n Permit Request 1206-70 &at67-/NC f3cu.45p�q c /1v� �t ems` - 4 Cis .yt2e GQ B�/Le L� &4-- i4.2-e- MU.�y Cvl`J K /Lf�4, -�c, ' SEA P �t{;t I7' Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay I Project Valuation /51 9Q10 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) /� Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ®/Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other C gcPl �� Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) r 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: ❑Ye ❑ No Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑,.new`size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size._ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ =� Commercial ❑Yes ❑ No If yes, site plan review # -' Current Use -S-4-0 Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name � 1 5 Telephone Number Address GO Get Li L 26P License # 7OM2_S/t-6S i .cl�_S , ��-- 4" Home Improvement Contractor# Of-1170 Worker's Compensation # Azk �o(OD/�0 / ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJE TWILL BE TAKEN TO SIGNATURE 6 DATE 4Z1041� 7 FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED, a . I .MAP/PARCEL NO... • e ADDRESS VILLAGE OWNER DATE OF INSPECTION: !';�FOUNDATION FRAME VP 6 ( (i-I2. -INSULATION: FIREPLACE ;a ELECTRICAL: ROUGH FINAL - PLUMBING: ROUGH FINAL , .GAS: s ROUGH FINAL 1 5 :',FINAL BUILDING:',: 7 - ` DATE CLOSED O.UT, . ASSOCIATION PLAN NO: • f The Commonwealth of Massachusem Department of lndusbzal Accidents Office of Investigations 600 )Washington Street Boston, MA 02111 www mass gov1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plnmbers Applicant Information Please Print Le�bly Name (Buse,ess/orgarnzaLiondndividnal): '14 �L Address: t O C.tl�Al d, Jir a City/State/Zip: AdA-4` VL4-, Wk�& Phone#:5®£r �L8- F2. 7Tmm an employer? Check the appropriate box: a employer with L_ 4. ❑ I am a general contractor and Ir[] ject(required): . employees(full and/or part-time).* have hired the sub-contractors construction I am a sole proprietor or partner- listed on the attached sheet. deling ship and have no employees These sub-contractors have, 8 Demolition working for me.in any capacity, employees and have workers' [No workers' comp. insurance comp,insurance.$ 9• ❑Building addition required.] 5. [] We are a corporation and its 10.❑Electrical repairs or additions 3.❑,I am a homeowner doing aE work ofEic=have exercised their 11.❑P ing repairs or additions myself [No workers' comp. right of exemption per MCiL I2 R oof repairs insurance required.]t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp.insurance rqquized.] *may applicant that checks box#I Est also$Il 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 outride contractors must submit a new affidavit Indirahr 9 such tMPIDY tors that check this box to must r tarhcdcmplo me additional sheet showing the name of the sub-contractors and shah whether or not those entities have employees If the sob coahsctors have emp]oYnes,they must provide their workess'c policy mzbcr, one,p ey m I am an employer that isproviding workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: ������" 6Z 0l/ Expiration Date:_ Job Site Address:_�/%�s /9(/� D .,s, / t 10&q Z City/State/Zip: .�Q��R 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 free up to$1,500.00 and/or one-year irtprisona of up to$250.00 a day against the violator. Be aent, as well as civil penalties in the form of a STOP WORK ORDER and a fine dvised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerd under the pains and pelz� erjury that the information provided above is true and correct Si tore: - Date: Phone#: 53& 1-fZ8-- g-&,?- Official use only. Do not write in this area, to be completed by city or town official City or Town: PermitUceuse# Issuing Authority(circle one): 1.Board of Hearth 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: i 9/,13/, 2011 8 : 26 : 39 AM 8740 m 02/03 PAMDCERTIFICATE OF LIABILITY INSURANCE DATE 09 2011 THIS CERTIFICATE IS ZSsum As A NATTER OF INFORMATION OILY AID CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT ArrIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OT INSURANCE DOES ROT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPEMMMTATIVE OR PRODUCER, AID THE CERTIrIGTE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, SUbject to the terms and conditions Of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endOrsement(s). rmvcxl cvsrAcr Frank L Horgan Insurance Agency Inc F 0 BOX 2501 Aeancss: .. eaovuan Hyannis, Imo+, 02601 - as0®Ise arrmnaO csuavacc "Ic c DSURED asuae A:A.I.K. Mutual InsA-�^�'e 33758 Randall G Se�etish aMHUOt B: dba R G Sweetish Builder am1¢R c: ` 10 Wheeler Roads D: Marstons Mills, MA 02648 � Ivsinum r: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS ZS To CRRTIFY TEAT'H E POLICIES OF INSURANCE LISTED BELOW RAVE BENT ISSUED To TBE INSURED NAMED ABOVE rOR Tag POLICY PERIOD INDICATES). NOTWZT9STANDING ANY RoQU1REMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WE='IBIS CENTTPICATE 2MY HE ISSUED OR MAY FNiTAIN, THE INSURANCE RrrORDID BY THE POLICIES DESCR=1U)MMX33 IS SUBJE r TO ALL TUZ TER KS, ]EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. Lr MTS SHOWN IDLY HAVE BSR7 REDO®BY PAID CLAffi. z>a POLICY RUBBER POLICY Err POLICY EZP LDSITS t� TYPE OF INSURANCE tn/nn=) taA/ASRr1r) GENERAL LIARILITZ ENZ OCCIRANCL i ❑COMmRCIAL GEITRAL LIABILITY nlaanE TO IIrlTLD i laLtI¢SIEA.DacDzttnee) ❑❑.—!ND! ❑OCCUP NED ffi (A"ene Petaml) i ❑ REMOIOi A ADV INDIE i ❑ MaIraII.AGGREGATE i OEA'L AGGREGATE L1141T APPLIES CA: OLICY ❑PRaTCCT❑LOG TaaIUCtS- ❑P e i AUIQDHII.R LIABII.ITY CamIan sue:- (ee.e identl ❑ANT A. strouY IDtDa ❑ALL 00ED AUTOS ❑SCBLDULTD AUTOS �TL��?i•'aa2Amt) i ❑tlIPED A0109 I I l��� i nItcs-aam AUTOS i ❑ i ❑UN3..A L. ❑OCCUR ZADI OCCURl2EXCE i ^ ❑EXCESS LIAR 11 CLAIM WADE )AOMLMIE 6 ❑Devvcxxm.E i ❑aEITAITm i i WORKERS CORSPENSATION arx- roar Lma an an EI12LOYEES LIBBII.ITY THE PROPRnRbR/PARTNERS/ E.A. EACH MCIDENT 6 100,000 A EXECUTIVE OFFICERS ARE ❑ incl ® excl 7 02 4 56 6 012 011 04/19/2011 04/19/2012 E.L. DISTANT-POLICY LIKII 6 500,000 E.L. DISTASE-cA Ta O= 6 100,000 CnAt• S MSMWTIM Or OPERATIONS Da LDCATIOBs: RANDALL G SWETISH IS NOT COVERED BY THE WORIZERSICOMPENSATION POLICY. CERTIFICATE HOLDER CANCELLATION TOWN OF SAN13RICH SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 8E CANCELLED BEFORE THE EINDATION DATE TREREOr, Nor=WILL BE DELZVM= Xff ACCORDANCE WITH TOM 16 JAN SEBASTIAN DRIVE POLICY PROVISIONS. SANDWICH, MA 02563 4718 �lassuchusetts- DcPartme nt of Public Sut'ct} rT Re:Lulations and Standards Board ()t Building. erv`isor ;License 4 sup ::••, _a C anstruction ;License: GS 10219 Restricted to: 00 RANpALL G S\N ETISH ; 10 WHEELER RD MA 02F48 ARSTONS MILLS., :. 'y�l iration: y13120'1 Exp 1 Tr#: 6021 ('unu»i"iuner I Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supen isor License: CS-010219 RANDALL G SW�ETISH', 10 WHEELE9 RD MARSTONSjVIII� i'11A??:02648 °J--�.- �%� t��►�J Expiration commissioner 02/13/2014 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application # Z. t.6 Health'Division Date Issued txU Conservation Division Application Fee Planning Dept. � '• ,Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/ Hyannis Project Street Address Village �AV�4t ' Owner Te►-cxru a' f40 �-2. Address, Telephone Permit Request Q�PA�Q- R �� �rl�ssS -�n �c�el� -S /L%�r4in- /1,r� �2uSsgS 45 Square feet: 1 st floor: existing 1100 pro posed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation ,d 0610 Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure 66 A6 ? Historic House: ❑Yes ❑ No On Old King's Highway: U Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Y-2- Gam- w 64&&4-. Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) 105z Number of Baths: Full: existing ,,At.OH-R- 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 � o Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stoves❑`es ❑ No =D z Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing Lf�newgize_ Attached garage: ❑ existing 0 new size _Shed: ❑ existing ❑ new size _ Other: LO -v z Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ D Commercial. ❑Yes ❑'No If yes, site plan review# N - Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name Telephone Number Address to ���L� l`fX License# & mn:15 �l[J Home Improvement Contractor# J0 G#70 ® �(P Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE-9-oh-0 FOR OFFICIAL USE ONLY APPLICATIONS# i '... DATE ISSUED :...MAR./PARCEL N0: ' s .ADDRESS: - VILLAGE i' OWNER DATE OF INSPECTION: T � I FO.UNDATION> ;�c,�5 FRAME OK oo O �� z -'FIREPLACE i ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS , ROUGH RuU, ., ;c ,. FINAL t.r FINAL.BWIkDING`1 3 zDATE C,LOSED-OUl.... s ASSOCIATION PLAN NO. r r Town- of Barnstable Regulatory Services t - = Thomas F. G-iler, Dixector • ,,srAec lho b i 6)F SA, ,�� Building Division • . Thomas Perry, CBO,Building Commissioner 200?vfain Street, Hyau s,MA. 02601 ww-,v.town.barnsta ble.ma.us Fax: 508-790-6230 'Office( 508-862--4038 PLAN REVIEWW't Map/Parcel. Owner: projectAddress The following items were noted:on reviewing: / N Reviewed by: ::�Co� s spate: r� l�.T.1�:wn....3e1�.—.r�,..: ..+F�.s..u•.�..b..+wtr�.r 4w..•�r•.•.. lsn,.. w...a.A��a..Y....A.Vi...,�......,t .w.-�..r....LA�.r_�...K..:A.... � ,.. J .., •tw... �u;�:.t..L.�.y..F'�`.A�..t..�f-f.-�.Ix.{.n tl�thi..f........,a.i �ip�,�` ,lA. The Commonwealth of Massachusetts 6 Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 s www,mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): �rVWw� ►'1 � �� Address: a) LAJ City/State/Zip: �'& Phone #: Are Y1041an employer? Check the appropriate box: Type of project (required): 1. 1 am a employer with�_ 4. ❑ 1 am a general contractor and I 6 ❑ New construction have'hired the sub-contractors.. . employees(full and/o act-time --7.-M -`�--"•Remodel_....g. 2.El am a sole proprietor.or pa ner- listed on the attached sheet. in ship and have no employees These sub-contractors have g, ❑ Demolition working for me in any capacity. employees and have workers' 9 ❑ Building addition o workers' comp. insurance comp.insurance.$ [N 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] 3.❑ I am a homeowner doing all work officers have exercised their 1 1.❑ 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 13.0 Other employees. [No workers' comp.insurance required] "Any applicant that checks box 4) 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 now 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. /� � �/�.� �� �J C Insurance Company Name: 1�'�/I/1' - - - - Policy#or Self-ins.Lic.#: /� � Zf9<�0 ¢6f�L� Expiration Date: e Z I Itz ZO Job Site Address:�t � ��7 '�` "" '� "�°�'Y/State/Zip: ®�%� Attach a copy of the or ers' comp nsation 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 tify under tl pain enal 'es rjury that the information provided above is true and correct. Date: vv Si nature; �p �y Phone#: u v "✓ Official itse 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 ofBealth 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: Information and fnstructions emploers- Massachusetts General Laws chapter 152 requires all employers toprlhe)sery workers' kof another P under oanyor their contrac of hire, Pursuant to this statute, an employee is defined as '.,.every person in express or implied, oral or written." her gal eDtity, or any two An employer is defined as "an individual, partnership, association, al represent repron or esentatives of aedeceased employer, or°heore of the foregoing engaged in a Joint enterprise, and including the 1 g P employees' However the receiver or trustee of an individual, partnership, association or other legal entity, employing d who ccupant 4Df the owner of a dwelling house having not more tanlenance,�onstni lioneorlrepair work on 'n,.or the o such dwelling house ' dwelling house of another who employs persons to do ma 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 liance with the ce applicant tvho has not produced acceptable YNe they hidence of e onunonw alth nor any ofnts Political subd visions shall Additionally, MGL chapter 152, §25C(7) states enter into any contract for the oerforrimance 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), addresses) and phone number(s) along with their certificate(s) of insurance, Limited Companies (LLC)or Limitcom Liability ensat onansuranees If an ( )with DO employees LLC or LLP does h vte er than the Liability members or partners, are not required to carry workers p employees, a policy is required. Be advised that this Alsoaffidavit be surre to signay be banidtdnte thed to the Daffidavit.nlThe of affidavit should Accidents for confirmation of insurance coverage. Department o be returned to the city or [own that-the application for the pen-nit or license is.being requested,not the Depart Industnal Accidents. Shouldyou have any questions regarding the law if you f-ins are ured companquired to ies obtain should enter their compensation policy,please call the Department at the number listed bet yv . self insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. T e Department ons sment to h.acontact Provided gar space ing the the bottom of the affidavit for you to fill out in the event the Offic g an er. In addi Please be Sure to fill in the•permiUlicense num er'w ihicn be used need only submibone affidavit nd.icatpng'current that must submit multiple permiUl'cense appl�c Y g "all locations in (city or policy information(if necessary)abd under"Job Site Address"the applicant should write town)."'A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the out each applicant as proof that a valid affidavit is on file for future ore armAs or nolicenses. elated to any business or commercial veotu e year. Where a home owner or citizen is obtaining a p . (i,e. a dog license of 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 Cornmonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 TelA 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 4-24-07 www.mass.gov/dia y 6fIKE7 Town of Barnstable regulatory Services t BARNSTABLF, ' Thomas F. Geiler,Director T MASS o 59- N,� Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 tiv-rnv.town.barnstable.ma.us Fax: 508-790-6230 Office: 508-862-4038 Property Owner Must Complete and Sign This Section if Using A Builder , as Owner.of the sub)ect property hereby authorize to act on my behalf) in all matters relative to work authorized by this building permit application for: j (Address f Job) Signature of Owne Date ��!0�'14t✓ . Print Name If Property Owner is applying for pen-rut please complete the Homeowners License Exemption Form on the.reverse side. Town of Barnstable P�o�TIiF Tp�� o Regulatory Services ` Thomas F. Geiler,Director HARNsrABLE, 9� >~r� Building Division i639• �� plFD �a 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 tl 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- res., --Tisible 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 homeoer is fully aware of his/her responsibilities,many communities require,as part of the perm homeowner it 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:\WPFLLES\FORMS\homccxcmpt.DOC va ---------- 11 DI LJI U-3 cq �t X, Q3 1A to Ar 1 1 ^ f IA 5 ik I � X I is i. 1 � r I� As. I f Q� Z Y � $3 n 9 IQ 11 l `^1 p c„ 1' Y r -10 lof t '� Barnstable Old Kings Highway Historic District Committee 200 Main Street, Hyannis, MA 02601;TEL: 508-862-4787 Fax 508-862-4784 • �IA.Y$TA 6l`' T h(.LSS O r�O Af.�� `moo •-.' � t ' ' Sr'r r.•�•- Z _ APPLZCATZON, CERTIFICATE Off' AP1.R;�� Application is hereby made, with four(4) domplete sets;for the issuance of a Certificate of Appropriateness under Section 6 of Cliapter 470, Acts and Resolves of Massachusetts, 1973, for proposed work as described below and on plans, drawings, or Photographs accomoanying this application for: '10 JUL 21 Check all categories that apply; 1. BuildiniZ construction: ❑ New ❑ Addition Alteration 2. Type of Building: El Home ❑ Garage/barn 1 ,/Shed ❑ Commercial ❑ Other 3. Exterior Painting, roof E new roof ❑ color/material change, of trim, Siding, window, door 4. Sign : ❑ New Sign ❑ Exisbng Sign El Repainting Existing Sign 5. Structure: ❑ Fence ❑ Wall ❑ Flagpole ❑ Retaini.ng wall ❑ terulis court ❑ Other 6. .Pool ❑ swimming ❑ Other mari-made pool Type or Print Legibly: Date: �� —Address of proposed work: House 1I street: G+,_ A._ )village G��- _ ssessors Map Lot#— Description of Proposed Work: Give ar'ticulars of work to be done:_ /_ zm_ L/ _ r 1d_ej(5 f ,ems A.40i � ccrr��tJ _ .L!l� Gy�ce1�2 o u- 1 ,�z!+ - � �iu� f ifs c',�,,. Gv A to L --46 Z44� Agent or Contractor(print): Ziy ---Telephone#:6_YY E_ Address: CQ J — Contractor/Agent' signature: NOTE ;411 applications must be,sikened by t!e current orPner n Owner(print)--jj) . N. ` Telephone p#:-- ---- /%C' IZL✓� -- Owners mailing address: -------- Owner's signature: For committee use only. Tbis Certificate is hereby -If ,,r.. �c- I� Bate ! Members si t res a t> I Dj -, - Town ot Barnstable J U N 2 4'Rff — old Kin 's Fri ham_ ` omm ee T0U'It!pf i ht3 J TPJ T[ABLE I -- I�I5Ti1l,! ; P��E,EPV��IIONj iti of app al: i °FY"Sr°� Barnstable Old Kings Highway Historic District Committee 200 Main Street, Hyannis, MA 02601;TEL: 508-862-4787 Fax 508-862-4784 MAM po°`rFo MAC 4\ � -, � APPLICAIZON, CERTIFICATE TIFICATE OF APX ROPRIATEl\TESS Application is hereby made, with four(4)'C6mp"lete"set9;for the issuance of a Certificate of 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 all categories that apply; 1. Building construction: ❑ New ❑ Addition ❑/Alteration 2. Type of Building: El House ❑ Garage/barn L�J Shed ❑ Commercial ❑ Other 3. Exterior Painting, roof E� new roof ❑ color/material change, of trim, siding, window, door 4. Sign : ❑ New Sign ❑ Existing Sign ❑ Repainting Existing Sign 5. Structure: ❑ Fence ❑ Wall ❑ Flagpole ❑ Retaining watt ❑ tennis court ❑ Other 6. fool ❑ swimming ❑ Other man-made pool Type or Print Legibly: Date: Addre s/C�ds "s �of proposed work: House il ,_21�S-" (.Street: f a —L�1 ,Village G� prI _ ssessors Map Lot# Description of Proposed Work: Give particulars of work to be done: z,;_ j mw� L°�.tUd"4., (J gy f � c tr�c� �i G�l� dcC�le�L Agent or Contractor(print): Z�40P �[.� S _Telephone Address: Contractor/Agent' signature: _ NOTE All applications must he signed by t1 e current owner Owner(print): _ Telephone #: Owners malting address: Owner's signature: For committee use only. This Certificate is hereby PFjr Ei[YD t4: Date ` Members s t res U] JUN tj Town of Barnstable uU ' Committee T001 QI=BAR STAQLC NISTO>�IC PRE ERVAIION iti of appi at: 1 (�:IGAAI)-rrnunc!nld Kiroc Hirhwa00KHAlewAoolOY.11 CerlAooropriw!ness 07.doc Town of Barnstable Old icing's Highway Regional Historic District Committee CERTIFICATE OF APPROPRIATENESS SPEC SHEET ,41L Please submit 4 Copies Foundation Type: (Max. 18" exposed) (material -brick/cement, other Sidin Type Gc�6tt.GCJ EeGCIl!�L_ material: U ,c( U ,� Color: G�� C�� CPI- xapp- -,c ' &6 'J. ' Chimney Material: Color.- Roof Material: (make & style) -Zqp: LU 'on 1 F*'// �Tlr(9 Color: �CGe NL Trim material ��+-e Color: 60�4_f& Roof Pitch: (7/12 minimum) Z- Window.- (make/model) /L 11— material &V 60 LC color Size(s): Flwi X10 L bO Door style and make: material Color: w LA Garage Door, Style Size fob� Material Color wl� � Shutter Type/Material: Color: Gutter Type/Material: Color: _ Decks: material Size Color: Skylight type/make/modeU: material "----Color_ -- Size: APP Sign size: Type/Materials: 1 1 -- }Color: JUL 14 2010 ow Fence Type (max 6' ) Style , material }� 2 4 r: Town of Barnstable Retaining wall: Material: BA' Old King's Highway HI;T�u.IC k'RES�I,, � ,� Lighting, freestanding —"on building � -- —' illuminating sign Please provide samples of paint colors and manufacturers brochure of style of windows, doors, garage door, fences, lamp posts etc ` O A.DDI ZONAL INFORIMATZON: - ` All. Xtj t Signed: (plan preparer) print name � � /YGJ"T` tZ tel. no. Lo tion of application: Street no. Street Village 2 Plans shall include the following: Name of applicant, street location, map and parcel. _Name of Builder Designer, or architect; original signature of plan preparer and stamp; plan date, and all revision dates. ALL NEW HOUSE OR COMMERCIAL BUILDING PLANTS MUST HAVE AN ORIGINAL SIGNATURE AND STAMP, IF ANY,BY A REGISTERED ARCHITECT, MEMBER OF ALBD, OR A LICENSED MASSACHUSETTS HOME IMPROVEMENT CONTRACTOR, UNLESS THIS REQUIREMENT IS WAIVED BY THE OKH DISTRICT COMMITTEE. A written and drawn scale. Elevations of all (affected) sides of the building, with dimensions including height from the natural grade adjacent to the building to the top of the ridge; location and elevation of finished grade, roof pitch(s), dormer setbacks; trim style, window and door styles. Changes to existing buildings must be clouded on drawings. LaykiScaping plan, 4 copies drawn on a certified perimeter plan containing the following information: _Name of applicant, street address, assessor's map and parcel number. Name, address and telephone number of the plan preparer; plan date and dates of revisions. The location of existing and proposed buildings and structures, and lot lines. Natural features of site (e.g. rock outcroppings, streams, wetlands, etc.). _Existing buffer areas to remain. Location and species of trees outside of buffet-areas greater than 12"caliper to be retained or removed. The location, number, size and name of proposed new trees and plants. Driveway,parking areas, walkways, and patios indicating materials to be used. Existing stone walls, and proposed walls including retaining walls for slope retention or septic systems. (for removal of stone walls, file Demolition Form). _All proposed exterior lighting and signs. Sketch or photos of adjacent properties, (1 copy only) A sketch(s) to scale or photographs of nearby adjacent buildings, where present, along both sides of the street frontage, showing the proposed new house or commercial building in scale and in relationship to the existing buildings. Please discuss with staff if you do not think this is relevant to your application. Photographs of all sides of existin s �eaffiis, or being added to (1 set only). Fee according to schedule. 1 4 1 l� Please complete the following: .��ot�N9hway I,( JUN °�� 4 bid W� ,rim _ Cow Existing but ing, foot print: n riiv OF EARNSTAGt-E Building 1 7 �5ea e),gw0 sq. ft. Building 2 NI T ? 1�, RtSER!!q;iQN Existing Building, gross floor area, including area of finished basement: Building 1 [ sq. ft. Building 2 v building or addition, foot print: Building 1 sq. ft. Building 2 T L ft uildhag or addition, gross floor area, including area of finished basement: B` tilding 1 sq. . Building 2 4 .d„,JnKH(P,-/Annrnnrinfnnesc07.doc APPROVED JUL 14 2010 010� 4 Town of Barnstable Diagram of sign, showing graphics, size, deli and hei ht of post, color and rq����Highway gr gn, g gr p design g P ittee Spec sheet. Site Plan on a GIS map or mortgage survey, OR photographs OR to-scale sketch of building elevation showing location of proposed sign; and any tree to be removed near a freestanding sign. Fee according to schedule. 5. FOR LIST OF ABUTTERS: PLEASE SEE OICH STAFF SIGNED (plan prepares) �1-i� 6 J� Print � (P��� co Date: l0I2,4Y 10 Tel. Phone o's: ID b NOTE 2:g JUN 2 4- TOWN CE BARNSTA�LE The Old Kings Highway Historic District Committee MAYDENYINCOMPLETE APPLICATI N IISTORIC RESERVA IQN ATTENDANCE AT MEETINGS: If the applicant or his/her representative is not present during the hearing is scheduled, the application may be either CONTINUED OR DENIED APPEAL PERIOD APPROVED PLANS PLAN PICK UP There is a fourteen (14) day appeal period for approved plans. This is necessary for each Certificate of Appropriateness and/or Certificate for Demolition issued by the Old King's Highway Committee. Plans approved by the Old King's Highway Regional Historic District Committee may be picked up at Growth Management,Regulatory Division, 200 Main Street, Hyannis, after expiration of the 14 day appeal period. If the 141h day falls on a Saturday, Your plans will be available the afternoon of the following business day. DENIALS Applications that are denied may be appealed to the Old Kings Highway Regional Historic District Commission within 10 days of the filing of the decision with the Town Clerk. For more infonnat' seethe Bulletin of the Old Kings Highway District Commission. BUILDING PERMITS, OTHER AGENCY CONTACTS In most instances, before commencing work, a Building Permit is required. The Building Division will require a certified plot plan for new construction and/or demolition. Commercial work may require Site Plan approval. Demolitions: the applicant`should check with the Building Division as to conformance with Zoning requirements. Other Regulatory Agencies at 200 Main St, Hyannis MA 02601: Building Division 508-862-4038 Conservation Division 508-862-4093 Health Division 508-862-4644 QUESTIONS ABOUT YOUR APTLICATION? PLEASE CALL THE BARNSTABLE OLD DINGS HIGMVAY OFFICE AT 508 862-4787 5 PROPOSED REPAIRS TO MEETING MOUSE FARM SHED EXTERIOR • Cut approximately two feet of wall siding and sheathing • Remove rotted sill plate and stud wall shoe • Add one and one half courses of concrete block to foundation where sill is being replaced • Install new pt sill plate and stud wall shoe • After doing interior repair(adding new wall studs as needed) install new plywood sheathing to repaired wall area • Install new white cedar shingles to stripped wall area to match existing wall covering • Repair all rotten/.damaged trim boards (rakes,fascias and soffits,corners,door and window trim) • Prep and paint all exterior trim (white) . • Re-roof with typical three tab asphalt shingles • Replace damaged entry door with similar new steel door • Replace damaged (gone)overhead door on gable end of building • Rebuild, prep and paint existing cupola R1r y L 14201� of eatoslabae t�nm ,S Nighw Y old��itlee , j , Bvalloizgrrg�� osik:r(FG'3? e` es License or registration valid*or indiyidul use only - HOME IMPROVEMENT CONTRACTOR before the expiration date: If found return to: Registration: 109470 Board of Building Regulations and Standards Expiration:'9/16/2010 Tr# 273661 One Ashburton Place Rm 1301. Boston', Ma.02108 RANDALL G SWETISH.;BUILDER, RANDALL SWETISH 10 WHEELER ROAD MARSTONS MILLS, MA.02648 Administrator Not valid w thout signature Massachusetts- Department of Public Safety . Board of Buililin Rcl;ulations andStandards Construction Supervisor License A. License: CS 10219 Restricted to: 00 RANDALL G SWETISH 10 WHEELER RD MARSTONS MILLS, MA 02648 Expiration: 2/13/2012 ('innmissiuncr Tr#: 16021 I I J JL\ NOTICE NOTICE TO TO EMPLOYEES EMPLOYEES f The Commonwealth of Massachusetts DEPARTMENT OF INDUSTRIAL ACCIDENTS 600 Washington Street, Boston, Massachusetts 02111 617-727-4900 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: ASSOCIATED INDUSTRIES OF MASSACHUSETTS MUTUAL INSURANCE COMPANY NAME OF INSURANCE COMPANY 54 THIRD AVENUE, P.O. BOX 4070, BURLINGTON, MA 01803-0970 ADDRESS OF INSURANCE COMPANY AWC 7011076012010 02/12/2010 - 02/12/2011 POLICY NUMBER EFFECTIVE DATES Frank L Horgan Insurance P O Box 250 Agency Inc Hyannis, MA 02601 (508) 775-5830 NAME OF INSURANCE AGENT ADDRESS PHONE Randall G Swetish dba R G Swetish Builder 10 Wheeler Road Marstons Mills, MA 02648 EMPLOYER ADDRESS 02/09/2010 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 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 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 NEAREST AND BEST MEDICAL FACILITY NAME OF HOSPITAL ADDRESS TO BE POSTED'BY EMPLOYER TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 3� Parcel Z-- �J�.�o Permit# Health Division0 cam'1 1 c� 4_i Date Issued Conservation Division 3 0S Fee Tax Collector Treasurer Planning Dept. Checked in By Date Definitive Plan Approved by Planning Board Approved By Historic-OKH �IPre ervaat'Rn/Hyannis Project Street Address ZI ff Ja Ic_�i s�a.�1WJ Village i�`� �' �S ` , Owner h ra.ry-^-isa �ONJ Address ZaV MA%w S+, Oyrie iii ►1/�i Telephone c5_08 lr Z _V 9 3 Permit Request die yynu eh� bv; ,i 0- . Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Valuation Zoning District Flood Plain Groundwater Ov Construction Type • Grandfathered: ❑Yes ❑ No If es attach su orti oc�tation. Lot Size y pp Dwelling T e: Single Family ❑ Two Family ❑ Multi-Family(#units) Age of Existing Structure 1 S � �$ Historic House: O Yes O No n Old King's Highway: ❑Yes ❑No Basement Type: ❑Full O Crawl ❑Walkout ❑Other �� Basement Finished Area(sq.ft.) Ba etnent 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: O Gas ❑Oil Electric ❑Other Central Air: ❑Yes O No ireplaces: Existing New Existing wood/coal stove: ❑Yes Cl No DeZarage ' ing ❑new size Pool:O existing ❑new size Barn:O existing ❑new size Attting ❑new size Shed:O existing ❑new size Other: Zo Authorization ❑ Appeal# Recorded O r Commercial O Yes O No If yes,site plan review# Current Use Proposed Use BUILDER INFORMATION / 2 Name C' �GzIM� Telephone Number 7 Address Z d4 2 �/�-J License# ( O _<77 ; Home Improvement Contractor# d Worker's Compensation# JW'Q-- 06"LA& ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE _ a FOR OFFICIAL USE ONLY y E' PERMIT NO. DATE ISSUED MAP/PARCEL NO. a o ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION f FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL Y r` GAS: ROUGH FINAL; FINA14BUILDING DATE'CLOSED OUT ' a> (� ASSOCIATION PLAN NO. :_ ' The Commonwealth of Massachusetts _ -- Department of Industrial Accidents 600 Washington Street Boston,Mass. 02111 Workers' Compensation Insurance Affidavit-General Businesses NIMM MM/-/ -/ � -- name: address: �1 i ✓K J t-A--thstate• r- \At AIAJ'5 ziy t� �p� vh=e# J J" � /d-.16Q 316 work site location(full address): ❑ I am a sole proprietor and have no one Business Type: ❑Retail❑RestaurantBar/Eating Establishment working in any capacity. ❑Office❑Sales'(including R#Estate.-Autos etc.) ❑I am an em to er with etn loyees(full& art time). BOther *L k-OJ I L I ,CJ_I am an employer providing workers' compensation for my employees working on this job, company game � '° ' address � i�l'•1• ' ;' .';.• •"�. . bone M.if nsdrence.co:. > DO I am a sole proprietor and have hired the independent contractors listed below who have the following workers' compensation polices: address: i:r city shone' .. insurance co. - o7ic''.# ' / coin'eri.!i5eiiie • ''``•``!'� :''j• . city phone##"c '°olicv# %' / NZO Faflure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of it fine up to$1,500.00 and/or one years'imprisonment as wen as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that p copy of this statement �ains to the Office of Investigations of the DIAfor coverage verification. I do hereby cert' and a d en s-efpe►' a information provided above is true and tarred Date � 5 Sigaature _r Print name `-� t2N L us lti�2�_ Phan.11 z official we only do not write in this area to be completed by city or town official city or town: permit/license# ❑Building Department OLiceming Board ❑check if immediate response is required ❑selectmen's Office ❑Realth Department contact person• phone#; ❑Other (tevned Sept 20M) T � 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 a�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 section 25 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,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. Please supply company name, address and phone numbers along with a certificate of insurance as all affidavits maybe submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the aff davit. 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 b'e used as a reference number. The 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 give us a call. i000aaiaaiaaioaaoaiioi The Department's address,telephone and fax number: The Commonwealth Of Massachusetts Department of Industrial Accidents WIN of wesdpadons 600 Washington Street Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617)7274900 egt.406 Ri n„ y�Jj J:{}��.z'.� 11�. f{i' �. "J � �3'f. �VL/A���I���A���•�j'�w�i'P�`�.�4��J'}a�' ` "":::��; T r l �i`Cq � i, ,j } ♦)� �j A � �d h 9���A'd 1 f t�7p rell tr ?`is"All �z.4eC�tyST'�Ysm ,®g� S Y f v �$ t• [rd k f a.l s' rb4 �•, � * .' ` 1,K � .: / fir��'. � f..,M1 ; ����+�,�,. �. � F t�•5;``t"r �.+�'� 3 /f6� C� l v a Al s `•�' ,S" d ^S? .. tax f i g-f ,. -ce 4 t d.": .�..,. ,fin '--^°h.,-"•�"t"..�:.� ?'" J. �+'`� p3. a� �� �J �"�e�}s &. � � Y a 1J�� � 'i. �11 F1 �"y r �' 2 y ��✓ .1�. �,t+i,����1. ��: r� 4 .v y'^�l,�rA'� ' • .'''� °.r'- S y'' tK+1i t J%>;..A. ���.....��yyy■■■■�'��1'Y�� , .�7 jsr � -.+C" ��:.. 't�( 'y �:ai pr vdau raer.G s.r. h 1 1 rA � 1 Map 15 �✓ #214 4;� 4 p154 C:\Conservation.dgn 8/18/2003 9:02:45 AM r � r� - Application to a' Old Kings Highway Regional Historic District Committee o in the Town of Barnstable for a �' v CERTIFICATE FOR DEMOLITION OR REMOVAL = `= r_s Application is hereby made, in triplicate, for the issuance of.a Permit for Demolition or Removal of a building or a structue-or part thereof, under Section 6 of Chapter 470. Acts and Resolves of Massachusetts.1973,for proposed work as described below o and on plans,drawings or photographs accompanying this application. TYPE OR PRINT LEGIBLY DATE 2 ds ADDRESS OF PROPOSED WORK a ' � ASSESSORS MAP NO. OWNER cb -V, ASSESSORS tOI N I Z—' r HOMEAOORESS 2—W �'^� • : ✓(4ml-3 a OZ&a l TEL NO. c�C/U ��/ ` q-/S NAMES AND ADDRESSES OF ABUTTING OWNERS: Include names of adjacent property owners across any public street . or way. (Attach additional sheet. if necessaryl. r-r- AGENT OR CONTRACTOR �. S ���r�s - I Vo TEL NO. 8 ADDRESS rC kay-le— w Y'V tq T _sz)e).' Z— o ,y DESCRIPTION OF PROPOSED WORK: If building is to be removed, give new location. Snap shots showing all views of building must accompany application. (Attach additional sheet. if necessary). . 0Pr-,0li�;0nj C4 end bv; laisw�S tnSnrke��`pt '� O/J Pla1J , �C Qlart C9N �r�/i^� -}o Scve. +L,e. se -VA) � bv,-I , ,y ✓Yv ke�cJ11,jit �-F d v r,b 19,.L cue,-xv� ate, ,� do es P o1 a p pvea n -A;J 5,.,' dYn . cAv be �aci i c 1 40 .fie, reryV'p—d . I Note: If approval is granted for relocation, a separate Certificate of Appropriateness is required for new location if within' the Old King's Highway Regional Historic District. SIGNED Space below line for Commiaee use. Ownw-Contnctor•Aa�t ee1Urf"_,y WEqCV The Certificate is her Date TLe#i TOWN OF BARNSTABLE ISTORIC PRESERVATION Approved ❑ - IMPORTANT: If Certificate is approved. approval is subject to the 10 day appeal period provided in the Act. Disapproved ❑ / I FP ............ �..` 2,M- ., c co n. . c:\ at,.d 4/2005 10:12:08 AM g �rll z j LL� . '� "rfyi` � �i:.rf ,�" r 2E i st f.7.;.�- 9'•1' !,�. �'� .' TTtt tt�L� } 6ii.�''l4 kAFa;� I-a� Ls' ,� 14 ,; -:. .mot"-F `!a5 i!'`ty ►.i:-.' WSP ,✓ it ,,,X� � *. i.,yfw t "•w�"',•!t.$�'F,"Va,ry„ a•'L x, �+�..•_ h Q., +�y,f Jam• 02 - 14 . 2005 15 : 09 D E C E dE FEB 1 5 2005 TOWN OF BARNSTABLE HISTORIC PRESERVATION i i I i I 1 tl�.�'�t ♦i .e � ��/ �1� � • �(� - tv�'�';7 ;7' '�^•'♦ai"♦ic;l, `�t j�. i. 31 A.Er Yir♦-A> ^f �t� S}3''•r� o�''t. ��^�.P '.r �, 1. ;���.�lt a�,� `c ♦ S it i,.>Y,}��l`+,�C.._ w�,�}z '�s .✓q�y ���. ►{ CAr..:`�'. _'� .. .'e�Cte.'.�� � �yr�r1.• Y ,�, v4 r3i94,'•Fy�i ..p oi .. ��` �v "xth / .OM..�.yi}*� �1�� a.� v/' ���cj• • ��', a_�i,,,,'z—` ..u..R �ti i �: •' g�"( ,Q�'� i" ++'� ti� '4 � 'r�"'� kP�� �tt'�` �� . _ '�'"4 f7'�'t.fw���l.,.s... ^S"��T3��...,C _ t a� �'✓� .-'•.. }{�'� D � y.�.t. �. r*�; 4 �`��� jL ft'l„ t.1.:�� ���,}"'�i!�1't' � ? i 1�,1.� .♦ .� �///SSS ^^^ i ff ��,ttt� i`� �vtd e�:rY'j '!'si z�7'�jJ k�r.�it�l '� ��i `�� �+� � '.•'1"r'rt ,^i. .i a~♦� z sy�'74 �'a,r:r �z a�rt•"' 1t�1:� q ,., f !,}� .�} `�" `i�.k� Y, sl.a� _",:+rizr A vz Yr* z � R.:.c. `. ,c,• �� •tom > �;t/' a r �tiQ�?Y���({F' 1Y:t"`ft �'n•�,D.. j♦v0. w -t ,•s.'Sti., n., �4 ,tip q'F�. < 1>�A"r ':r4.T .+. J.�`'%''s ��� :�"�...-.�.'�..�.�t�� ,. �'`l+���•J a''�off'-~.•�4"'t:o ''i..ti„ ,�K .r �"�;.s, ' � s t`,��'`��� �;_�s� f�t f M1�`.}mot �,�' � 31���LE..�3u;"� t �� �^GS-' � ,�j• <�l •'r 2005 f Town of Barnstable *Permit#,Qd1 j Fxpir rrrontlaf "a issae date .PRESS pE. [1ftl Re gumas FaGo Regulatory Services ervices F � 2 rector DEC 10 z007 Building Division C�k jd 9 0 TOWS OF BARNSTA Per ,CBO, BuildingCommissioner 0 Main Street,Hyannis,MA 02601 www.town.bnrnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 EXPRESS PERNHT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number �30012 Property Address 1 it [Residential Value of Work Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Contractor's Name 4�221-t;h 6-Ce_S a rr Telephone Number Home Improvement Contractor License#(if applicable) 136 3 z Z. Construction Supervisor's License#(if applicable)_ [ orkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name �-/ =t`T`� /�✓�� Workman's Comp.Policy# 2- ' 315 "362 999 " © 12 Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side [Replacement Windo door sliders. U-Value (maximum.44) *When 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. yA'copy of the Home Improvement Contractors License is required. 3IGNATURE: �:Fomu:expmtrg tevise061306 THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I m A , I , DATA Q3nssJ� r Liberty O�.5 ICE 354 mutu Workers Compensation and n.r ORMATION PAGE Employers Liability Policy COUNT NO. SUB ACCT NO. Liberty Mutual Insurance Group/Boston 1-362499 0000 LIBERTY MUTUAL FIRE INSURANCE CO. POLICY NO. TD/CD SALES OFFICE CODE SALES CODE N/R 1ST WC2-31S-362499-017 XX X WESTON 102 REPRESENTATIVE 3000 1 YEAR ASSIGNED 2007 Item 1. Name of MICHAEL GASPARD Insured DBA RENOVATION SPECIALISTS FEIN 22-9981405 Address ._225 GOSNOLD ST RISK ID 653331 , HYANNIS;MA 02601 Status 01 INDIVIDUAL. Other workplaces not shown above: SEE ITEM 4 i j Mo.Day Year Mo.Day Year Item 2. Policy Period: From 06-05-07 to 06-05-08 12:01 AM standard time at the address of the insured as stated herein. Item 3. Coverage A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3A. The limits of our liability under Part Two are: Bodily Injury by Accident 500,000 each accident Bodily Injury by Disease 500,000 policy limit Bodily Injury by Disease 500,000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any,listed here: SEE.END WC 20 03 06A D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE Item 4. Premium - The premium for this policy will be determined by our Manuals of Rules Classifications Rates and Ratil: Plans. All information required below is subject to verification and change by audit. Premium Basis Rates LINE 110 Estimated Per$100 Estimated Total Annual of RE- Annual Code Classifications No. Premiums muneration Premiums SEE EXTENSION OF INFORMATION PAGE Minimum Premium $ 500 ( MA ) Total Estimated Annual Premium $ 5,808 Interim adjustment of premium shall be made: ANNUAL This policy,including all endorsements issued therewith,is hereby countersigned by Authorized Representative Date 07-19-07 Loc.Code Term. Oper. Audit Basis Periodic Payment Rating Basis Pol.H.G. Home State Dividend�NE-W NEW BUSINESS 07-19-07 NR MA i GPO 4030 RI Copyright 1987 National Council on Compensation Insurance WC 00 00 01 A INSURED CLAY I ' The Comnionwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111' w}vw.mass.gov/dia ' Workers'Compensation Insurance Affidavit: Builders/Contractors/Eleetricians/Plumbers Applicant Information Please Print Legibly Nmne(Business/Organization/ladividual): -Address: City/State/Zip: 4,rU^rie_ 11�1 �.Zb�l Phone.#: j 00- y5'1- Are ou an employer?Check the appropriate box: :Type of project(required):. I am a employer with L• 1.[ 4. [] I am a general contractor and I 6 New construction . •'employees(full and/or part-time).*. have hired the sub-conhactors 2.❑ I am a'sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees . These sub-contractors have S. ❑Demolition Y for me in anapac capacity. employees and have workers' • working t3'• 9. ❑Bui7dmg addition . [NO workers' comp.r�r gr,ranCe comp.inanranc0.#' 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 bf exemption per MGL 12.❑Roof repairs insurance.required.]t c. 152 §IN,and we have no ] . 13.❑Other_ ' employees.[No workers , Comp.insurance required] -Any applicant fat checks box#1 must also fill out the section below showing their workers'compensation policy info nation. t HmaoovvnMYAo submit this affidavit indicating they are doing all work and then hire outside contreetors mutt subrnit a new affidavit indicating kuch. 1c ntractors that check this box must attached as additional sheet showing the name of the subcontractors and state whether ornot those entities have erMloyees. if the sub contractors have employees,8rey must providb 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. I Insurance Company Neme: Policy#or Self-ins.Lie. -362%49—'d t -? Expiration Date: fob Site Address• f y� City/Statemp: `rs l�hlt= Attach a copy of the workers'compensation policy declaraflou page(showing the policy number and expftation 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 tip tb$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORKORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the-Office of Investigations of the DIA for insurance coverage verification. ' I do hereby certify under thepains•andpenalties of per that the information provided above is true and correct Sitcnature // ? ( Date- o/U`7 r . Phone Official use only. Do not write b7 this area, tb be completed by city or town•officiaL City or Town- ' Permit/License# Issuing Authority(circle one): A.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5•Plumbing Inspector j 6. Other ` Contact Person: Phone M v 1 oFTME r Town of Barnstable Regulatory Services BARIMi►ues�B�� Thomas F.Geiler,Director 0.jg6 i63q. ' Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, as Owv6er of the subject property hereby authorize n1 ay-oo to act on my behalf, in all matters relative to work authorized by this building permit application for. (Address of Job) Signature of Date art Cor� Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:FORM&OWNERPERMISSION Town of Barnstable SHE Tp�� Regulatory Services BARNsmBm Thomas F.Geiler,Director HABs. 1639. p�0� Building Division jED MA't Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Rrcnv.town.b a rnstab l e.ma.us Office: 508-8624038 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 hermit. (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 fomn/certification for use in your community. Q:forms:homeexempt Town of Barnstable Op THE Ip� Regulatory Services Thomas F. Geiler,Director 3'� MASS, �e� Building Division racy Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www,town.barnstable.m a.us Office: 508-862-4038 Fax: 508-790-623( PERMIT#_a?-0DS4 FEE: $ S . SHED REGISTRATION 120 square feet or less A4 c F 21iA 7-3 C_ Location of shed(address) Village rf C `ia ru��✓ b/ 6—Of 36 z 2. 9 Property owner's name Telephone number ; /CS ' /Z f / 36 ('� RL �s Q�Z� Size of Shed Map/Parcel# . Cture Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? Conservation Commission(signature is required) n) Sign off hours for Conservation 8:00-9:30 &3:30-4:30 PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE � COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE. PLEASE SEE THE APPROPRIATE COMIVIISSION FOR DETAILS. THIS ]FORM. MUST BE ACCOMPANIED BY A PLOT PLAN s J Q-forms-shedreg REV:042506 ASPHALT SHINGLES SINGLE GLAZED, DOUBLE STRENGTH 0 WINDOW PANES o WHITE TRIM WOOD SHINGLES WEST ELEVATION MEETINGHOUSE FARM SASH HOUSE 8.21.07 - N.T.S. I 10'-4" WHITE TRIM WOOD SHINGLES . o ]FIE zo � o 0 WHITE WOOD DOOR SOUTH ELEVATION MEETINGHOUSE FARM SASH HOUSE 8.21.07 N.T.S. l 1 O,-4„ WHITE TRIM JIE l o ' WOOD SHINGLES to O ti WHITE WOOD DOOR NORTH ELEVATION' MEETINGHOUSE FARM SASH HOUSE _ 8.21.07 N.T.S. 12'-311 ASPHALT SHINGLES WHITE TRIM o o co i` o O WOOD SHINGLES WHITE WOOD DOOR EAST ELEVATION MEETINGHOUSE FARM SASH HOUSE 8.21.07 N.T.S. i r EVE Sign TOWN OF BARNSTABLE Permit * BARNSTABLE, ' y MASS. Permit Number: Application Ref: 200803756 20070202 i Issue Date: 08/19/08 Applicant: BARNSTABLE, TOWN OF (OS) Proposed Use: TAX EXEMPT MUNICIPALITIES Permit Type: SIGN PERMIT Permit Fee $ 50.00 Location 2135 MEETINGHOUSE WAY/RTE 149 Map Parcel 130012 Town WEST BARNSTABLE Zoning District RF Contractor PROPERTY OWNER Remarks MEETINGHOUSE FARM 4 SQ FREESTND BLK GRY WHITE 4SQFT Owner: BARNSTABLE, TOWN OF (OS) Address: 367 MAIN ST HYANNIS, MA 02601 c c- Issued By: .,::.;:. F ..T.IE.S:TREE . » »:.>:::.::::.>::: ::::.::::::.:......:.....::.::;.::: RD:. ..TI3AT I .vI YBLE RO P.OS:T.:THIS . A SO S S Town of Barnstable FINETgj� Regulatory Services' N `IF IBARNSTABLE G� Thomas F. Geiler,Director ansuvsrnsie. : 2f100 JUL 14 PPS 2: 00 9 KAs3. Building Division 1639. �0 Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA`0260t—•--- -- www.town.barnstable.ma.us DIVITION Office: 508-862-4038 Fax: 508-790-6230 Permit# b 7V1 Application for Sign Permit I;�••c.EN Mt lZ��aT 'FatL Applicant: Map & Parcel # i3 0 0 1 Z Doing Business As: Telephone No.5-08 - 'S Z t o L 3 Sign Location Street/Road: Zoning District F\f� Old Kings Highway? Yes No Hyannis Historic District? Yes Property Owner Name:-1 e" o v-- '6nrz+.►s. LL-- Telephone: Address: 3.(o Village: Sign Contractor �� 1�6r��ofool Name:���� �t�ri'� �•/�-�.p ..�(I- Telephone: Yo S • 7 7l - 7/ 1 7 Mailing Address: 1 155' O yb.,Z .. 6 U<iv-k 14 VS Description Please draw a diagram of lot showing location of buildings and existing signs with dimensions, location and size of the new sign. This should be drawn on the reverse side of this application. Is the sign to be electrified? Yes No (Note:Ifyes, a wiring permit is required) Width of building face Z7. 5 ft. x 10= x.10= Sq.Ft. of proposed sign + S I hereby certify that I am the owner or that I have the authority of the owner to make this application,that the information is correct and that the use and construction shall conform to the provisions of§240-59 through §240-89 of the Town of Barnstable Zoning Ordinance. Signature of Owner/Authorized AgentVQO—, Date: 7 1 8 Permit Fee: Sign Permit was approved: Disapproved: Signature of Building Official: Date: In order to process application without delays all sections must be completed. Q:I WPFILESISIGNSISIGA'APP.DOC Rev.9112106 veVrai uue i own or tsarnstaule, MA Page 87 of 111 h including painted signs, individual lettered signs, cabinet signs and signs on a mansard. WINDOW SIGN —A sign installed inside a window and intended to be viewed from the outside. § 240-61. Prohibited signs. The following signs shall be expressly prohibited in all zoning districts, contrary provisions of this chapter notwithstanding: A. Any sign, all or any portion of which is set in motion by movement, including pennants, banners or flags, except official flags of nations or administrative or political subdivisions thereof. B. Any sign which incorporates any flashing, moving or intermittent lighting. C. Any display lighting by strings or tubes of lights, including lights which outline any part of a building or which are affixed to any ornamental portion thereof, except that temporary traditional holiday decorations of strings of small lights shall be permitted between November 15 and January 15 of the following year. Such temporary holiday lighting shall be removed by January 15. D. Any sign which contains the words "Danger" or"Stop" or otherwise presents or implies the need or requirement of stopping or caution, or which is an imitation of, or is likely to be confused with any sign customarily displayed by a public authority. E. Any sign which infringes upon the area necessary for visibility on corner lots. F. Any sign which obstructs any window, door, fire escape, stairway, ladder or other opening in to provide light, air or egress from any building. G. Any sign or lighting which casts direct light or glare upon any property in a residential or professional residential district. H. Any portable sign, including any sign displayed on a stored vehicle, except for temporary political signs. I. Any sign which obstructs the reasonable visibility of or otherwise distracts attention from a sign maintained by a public authority. J. Any sign or sign structure involving the use of motion pictures or projected photographic scenes or images. K. Any sign attached to public or private utility poles, trees, signs or other appurtenances located within the right-of-way of a public way. L. A sign painted upon or otherwise applied directly to the surface of a roof. M. Signs advertising products, sales, events or activities which are tacked, painted or otherwise attached to poles, benches, barrels, buildings, traffic signal boxes, posts, trees, sidewalks, curbs, rocks and windows regardless of construction or application, except as otherwise specifically provided for herein. N. Signs on or over Town property, except as authorized by the Building Commissioner for temporary signs for nonprofit, civic, educational, charitable and municipal agencies. 0. Signs that will obstruct the visibility of another sign which has the required permits and is otherwise in compliance with this chapter. P. Off-premises signs except for business area signs as otherwise provided for herein. Q. Any sign, picture, publication, display of explicit graphics or language or other advertising which is distinguished or characterized by emphasis depicting or describing sexual conduct or sexual activity as defined in MGL Ch. 272, § 31, displayed in windows, or upon any building, or visible from sidewalks, walkways, the air, roads, highways, or a public area. § 240-62. Determination of area of a sign. A. The area of the sign shall be considered to include all lettering, wording and accompanying designs and symbols, together with the background, whether open or enclosed, on which they are displayed. B. The area of signs painted upon or applied to a building shall include all lettering, wording and accompanying designs or symbols together with any background of a different color than the finish material or the building face. littp://w,��ra,.e-codes.generalcode.com/searcliresults.asp?cmd=getdoc&Docld=56&Index=C... 5/9/1nB7 i uvvil ul LQ111JLQulc1 Lvlt1 rage opal opal 1. T. � r E. One projecting overhanging sign may be permitted per business in lieu of either a freestanding or wall sign, provided that the sign does not exceed six square feet in area, is no higher than 10 feet from the ground at its highest point and is secured and located so as to preclude its becoming a hazard to the public. Any sign projecting onto Town property must have adequate public liability insurance coverage, and proof of such insurance must be provided to the Building Commissioner prior to the granting of a permit for such sign. F. Incidental business signs indicating the business, hours of operation, credit cards accepted, business affiliations, "sale" signs and other temporary signs shall be permitted so long as the total area of all such signs does not exceed four square feet and is within the allowable maximum square footage permitted for each business. G. When a business property is located on two or more public ways, the Building Commissioner may allow a second freestanding sign, so long as the total square footage of all signs for a single business does not exceed the provisions of this section. H. When two or more businesses are located on a single lot, only one freestanding sign shall be allowed for that lot, except as provided in this section, in addition to one wall or awning sign for each business. If approved by the Building Commissioner, the one freestanding sign can include'the names of all businesses on the lot. I. One awning or canopy sign may be permitted per business in lieu of the allowable wall or freestanding sign, subject to approval by the Building Commissioner. . J. In addition to'the allowable signs as specified in this section each restaurant may have a menu sign or board not to exceed three square feet. K. In lieu of a wall sign, one roof sign shall be permitted per business, subject to the following requirements: (1) The roof sign shall be located above the eave, and shall not project below the eave, or above a point located 2/3 of the distance from the eave to the ridge. (2) The roof sign shall be no higher than 1/5 of its length. § 240-66. Signs in industrial districts. I The provisions of§ 240-65 herein shall apply, except that the total square footage of all signs, while normally not to exceed 100 square feet, may be allowed up to 200 sq l are feet if the Building Commissioner finds that larger signs are necessary for the site and are within the scale of the building and are otherwise compatible wish the area and in compliance with the provisions and intent of these regulations. I § 240-67. Signs in OM, HG, TD, VB-A, and VB-B Districts. [Amended 6-1-2006 by Order No. 2006-136] The provisions of§ 240-65 herein shall apply except that: A. The maximum allowable height of all signs is eight feet, except that the Building Commissioner may allow up to 12 feet if he finds that such height is necessary for the site and is compatible with the appearance, scale and character of the area. B. The maximum square footage of all signs shall be 50 square feet or 10% of the building face, whichever is less. C. The maximum size of any freestanding sign shall be 10 square feet, except that the Building Commissioner may grant up to 24 square feet if he finds that the size is necessary for the site and that the-larger size is in scale with the building and does not detract from the visual quality or character of the area. § 240-68. Signs in MB-All, MB-A2, MB-B and HD Districts. [Amended 7-14-2005 by Order No. 2005-100J The provisions of§ 240-65 herein shall apply except that: A. The maximum allowable height of signs shall not exceed eight feet. B. Freestanding signs shall not exceed 24 square feet in area. C. The total square footage of all signs shall not exceed 50 square feet. http://,A,\�,\i,.e-codes.eeneralcode.com/searchre.s>>lts.asn?r`,,,(1=aPtr1r)r.9-TlnrTrl=SA Q T„rlP.•=(' cioi)nn' D o4 SAO LA ® � ® x S Meetinghouse Farm, Inc. October 10, 2007 Fact Sheet for Sign Application Size: Approximately 30" by 19 112" Color: Combination of gray/white/black Gray Background White Lettering Black or White Detail on edge/letters Lettering:- 2 112 {{ to 3" Times Roman Design: Two-sided Arched lettering for Meetinghouse Straight Horizontal for Farm Small graphic at beginning and end points of arch Location: Left of driveway when facing site. Mounted on a-post with wrou ht iron hanger. i T� r 4i r. r �! C! �A`�. • to ~ �r t 'a.. 51.�'. � ''` AVA i. OM f �.. �`J 31.f1fff.. � wb. A •�%. �r,�i`,ef Y;•Y 2�#� ,Y � -�•��J vAt `y r. Y• P S If, 'a' s .70 _ �� , 1� ,•�R lid } _ 8 �.Y:'y- �, ,l 1 A AM +` .•1:.i '� t h.,4,.k``� ��. �R1 tii� •�L. s'K}'�,yM.y�-`!�,'-i , �* :�+' ,,. At �' x, t i, �a•. yam» i , .+fir•: a' � •! ���a ► a s • � r .� k� ti `1 k �+ ►n' . Town of Barnstable Old.King's Highway Historic District Committee 200 Main Street,Hyannis,Massachusetts 02601 (508)862-4787 Fax(508)862-4784 \My o� MINOR MODIFICATION TO PRIOR APPROVED PLAN ' 972 CAM Rules and Regulations, Section 1.03(2), 1.03: General Procedures V ," a. Only minor changes be roved b the Committee without the filing o a:new (2�) � ) Y g �' approved Y .� � g .f application and a new hearing. Minor changes include alterations that can be done without a detrimental impact on the overall appearance of the project such as altering a single window or door change or a minor change of colors. All minor changes by amendment will require the local Committee's or its designee's approval. Submit 2 copies of the application and supporting materials and documentation Applicant(s),print nameEE'f"j Address ofproposed work x,.1 2t35• Nle�T:,�crtoy s WAY \A/6s.- etaXNsiA3LE, '_f4 House No. Street Village Assessors Map.and parcel no. t 3 0 o f 2- Date of approval of.Certificate.of Appropriateness. A o — l o — 6 7 Proposed Minor Modification: TU 11 ernl 3 0" X 1 q��2 - t3 eu-kyR au N D C o�o2 '7?? $E GNaNG-�Q �i�oty 5I fr0?-05'r AS A NNoD D V'051- 1?AtM1-00 �•-�i��4r✓ - v�!o u Lam. 1_�K.E � L t+�.,.t GE "r'o �,t.,,4c.:1L y T'E�r.:. po sT of TFI C SAMC H E1e.14T' Tb MAr6H 1-HE APFao,�rEo 73J-Ae-r, 3nacW-6T �µE S3�� u S1'�"�L 1�oS i L�/o ur..D !3 E Z.," t� 'DI o►NIE r e� Signature of applicant: (s--. N T;• Print name: t�t-LSp,) tel no. 5-0_S: •.3.,c 2-- (0 2..3 Ceu. -7.7 4 - 4`i f . o s yz APPRO D/DISAPPROVED: signed CHAIRMAN CO BUILDING COINLNIISSIONER : ti APPROVED C-lbocuments and SettingsNecollikV Ocal SerdngslTemporary Internet FUesIOLKIIOKHMinor Modifrcotion Form 07.dae JUL O 2008 1 Town of i3am�9hwaY stable old committee i Meetinghouse F October 10 arm, Inc. - 2007 Fact Sheet for Sign Application Size:. .Approximat . ely-30" by 19 /„ Color;. Combination of Gray Back gray/white/black ground White Lettering Black or White Detail on edge/letters Lettering; 2 / « to3„ Times Roman APPROVED - Design: T JUL 0 8 2008 WO-sided Town of Barnstable , Arched letterin Old King's Highway g for Meetin Committee hou Straight . g se r Horizontal for Farm Small _graphic at beginnin g and end - points of arch ' Location; Left of driveway VeWay when facing site. Mounted on white post with .wrought iron ha . nger. . i I � 4 CM Q U Cn APPROVED p JUL 0 8 2008 Town of Barnstable Old King's Highway Committee f E Department of hidustrial Accidents Office 8UHMs119211ons "" bllll a.0in-� Jf �►tun Street �_.. n 4 � \ Boston. Afusv. 02111 Workers' Compensation Insurance Affidavit Annlicant tnftirmafion: - /rkTie PRINT lej bjy name: drChona I am a homeowner performing all work myself. ` 0 1 am a sole proprietor and have no one working in any capacity r • _.ty:-•+.r..jj �r�-*17.'.�':"+LeT+c7a.r�_T+.r'rwnrXr—�e.+.AFr+^.�'�`r..••.�+`.`aMT.�a�Pf� _ •��^�r..•�_r"�T+e-.--•—��•r., jl• .- �-1 am an employer providing workers' compensation for my employees working on this job. r ;K e n nap name: iddress: /� t� G'J x— h•: s�� 1-f ci � G /�!/ G f� phone it• insurance co. t_J C / solid# I am a sole propri or, general contractor omeowner(circle one)and have hired the contrm;iors listed below who have the following workers compensation polices: corn[mv name: 3 •t d r s: r p. ( l insuranccco. ���"�!�''7��� �/�aT pglicv#! ' _..__...-__sue._ --•••-• �.c•'=- - -:+�`e�.-J-,->... -11•�:�;.ve-.�1t^i= ;per::"`-�'J1Y,3�Y--1�'7T;rs�+,'�i-'-i"=;1i�..,.•�.�..t,:-;,TT�`:9:t^44%.�z!a'"a.L.��.e ornrianv name: address: phone ` insurance co, policy 9 Attach additional sheet if riecess:it ;: T�' -- i�acr.,f:� ;______.*.` "?"%c.'• - A.�_ �� __ Failure to secure coverage as required under Scctionf:5A of MGL 152 can lead to the imposition of criminal penalties of a fine up to S1.500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP NVORK ORDER and a fine of S100.00 a day against me. I understand that a cope of this statement may be forwarded to the Office of W-cstigations of the DIA for coverage verification. 1 tlo herehr ccrrif-under the pains nr vralties ojperjun•1/1 the in ormation provided above is true and correct. Si^_ aturc Date d Print name !. ��y N/ �f= /0'1 Phone# lJ -7 ofGciai uc nnl� do nut ss'rite in this area to be completed by eih•or town official city or to%%n: permit/license q rIBuilding Department E Licensing Board i. Z] check if immediate response is required �Seleetmen's Orrice C]flealth Department contact person: phone N. r JOther Ue,nm;.oc rl4f DEPARTMENT OF PUBLIC SAFETY COMSTRUC.TIOM SUPERVISOR LICENSE Number: Ex fires. CS P Birthdate: �12165 01/18/2000 #1/18/1955 Restricted:To: 11 LARRY D NICKULAS BOX Sl/ NEST BARNSTABLE, MA Engineering Dept. (3rd floor) Map Parcel Per it 4� 3 ;L l,��� House# nj Z7-f Date Issued 7f i k IF of Health(3rd floor)(8:15 -9:30/1:00-4:30) Fee I O Conservation Office o -9:30/1:00-2:00), .t Planning De floor/School A ldg.) 1►�►o, S� nitive Plan Approved by Planning Board 19 ; BARNSTABLE. TOWN OF BARNSTABLE Building Permit Application Project-StreetAddress L Village �• w Owner J of Address ° d?c-' 12dx, 1--a L✓ /.S Telephone 2. -Permit Request �'P �C Chi�l irl fC Cc./ c%��oG•� First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ G Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family ❑ TwoFamily ❑ 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 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 Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Vommercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use Builder Information / Name ZzLc,�,vel? d, cc• Telephone Number Address (f d v- License# S'-f c o d/Q C/�,r.•� Home Improvement Contractor# Worker's Compensation# ' NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CO TRUCTION BRIS RE LTING FROM THIS PROJECT WILL BE TAKEN TO l�UL SIGNATURE . DATE 7 c BUILDING PERM DENI D FOKTHE FOLLOWING REASON(S) 114-4- 61M FOR OFFICIAL USE ONLY PERMIT NO. -- DATE ISSUED MAP/PARCEL NO. ADDRESS - VILLAGE ,:_ OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH - FINAL FINAL BUILDING a: DATE CLOSED OUT ASSOCIATION PLAN NO. f CAPE COD COMMISSION U 3225 MAIN STREET P.O. BOX 226 c� BARNSTABLE, MA 02630 9ssA vS��� (508)862-383628 CH FAX(50 ) E-mail:frontdesk®capecodcommission.org June 9, 1998 Ralph Crossen Barnstable Building Commissioner 367 Main Street Hyannis, MA 02601 BY FAX 7fg0 - t0 230 Re: Conant Nursery Trust, West Barnstable Dear Mr. Crossen, I understand that the Barnstable Old Kings Highway Historic District Committee has approved the demolition of most of the greenhouse. buildings and the workshop shown on the Conant Nursery Trust site. A copy of the plan and the Certificate for Demolition were received by the Cape Cod Commission on May 26, 1998. The Cape Cod Commission decision dated February 26, 1998 requires that prior to any further division or development of this property "beyond continued use and operation of the nursery," the applicant must submit a Phase 2 development plan for review and approval by the Cape Cod Commission. The Commission considers the greenhouse and workshop as part of the nursery use and thus believes that their demolition is not subject to Commission review and approval. ?/ ` 1 Any other development of the site requires filing with the Commission pr T--to issuance of local permits. In particular, any development activity within the designated open space areas is prohibited. Additionally, prior to any development activity or issuance of a building permit for Lot 2 (the residential lot on Cedar Street) the decision requires a Certificate of Compliance from the Cape Cod Commission. If you have any questions, please feel free to contact me. Sincerely, Sarah Korjeff Preservation Planner CC. Larry Nickulas, applicant Sumner Kaufman, CCC representative Audrey Loughnane, Town Councilor Application to �,�.•,,,� ` Old Kings Highway Regional Historic District Committee 1998 116 . in the Town of Barnstable for a } CERTIFICATE FOR DEMOLITION OR REMOVAL Application is hereby made, in triplicate, for the issuance of a Permit for Demolition or Removal of a building or a structure or part thereof, 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. G Z? TYPE OR PRINT LEGIBLY op��n� l��us.� GATE Z/3 ,S� ADDRESS OF PROPOSED WORK ��`(/ ASSESSORS MAP N0. OWNER 60 4C~1 -C�-" / F ASSESSORS NO. y } HOME ADDRESSA S TEL NO. j L 1 NAMES AND ADDRESSES OF ABUTTING OWNERS: Include names of adjacent property owners across any public street ti or way. (Attach additional sheet, if necessary). s s Ste j 5 � � 10g) AGENT OR CONTRACTOR. i r� G, TEL N0. ADDRESS _�V // y sa /. �• s .t DESCRIPTION OF PROPOSED WORK: If building is to be removed. give new location. Snap shots showing all views of "I building must accompany application. (Attach additional sheet, if necessary). G/I/ct C`j Note: If approval is granted for relocation, a separate Certificate of Appropriateness is repwired for new location if within the Old King's Highwa Regions is o`� s USIGNED 1 er-contrector•Agent 3 Space below line for Committee use. +the Certiti e 'shereby a eL 7n6lea-M W ACC 2 3 ;....,. k Br<_LD KINGS HIGHWAY _. ti Approved ❑ IMPORTANT: If Certificate is approved. approval is subiect to the 10 day appeal period .) provided in the Act. Disapproved ❑ I t 6 ; 0 Addendum 2: Certified Abutters List 10/27/97 Gary Lannquist Dennis Mcwilliams Wayne Miller 3 Wbodside Cir. 45 Cedar St 8 Wright Farm Sturbridge, Ma 01566 West Barnstable, MA 02668 Concord Ma. 01 742 David Ross Town of Barnstable .- Robert Leeman 60 Wid eon_Wa -Oar & Line Road g 367 Main St West Barnstab e,MA 02668 Hyannis Ma. 02601 Plymouth, Ma 02360 Joseph Dikelmus Russell Petersn . 136 Cedar St -86 Willow St West Barnstable, Ma .4: Yarmouthport,MA 02668 02675 Viche terfieid 22 Cedar S St John Scandlen William Nickulas 1 / W 66 .-Blanid •Road P.O Box 395 fnlst ,Barnstable, Maw Osterville, 'Ma. 02655 W. Hyannisport,Ma 02672 02668 - � i George Leclerc Town-of Barnstable 86 Cedar St Conservation Commision Stephen Lawson ; West Barnstable,Ma 02668 367 Main St '218 Willow St Hyannis,Ma 02601 West Barnstable, Ma 02668 Theodore Whitney / Eric Hokans William Maki �.. n.. RO;X -V2 P.O. Box 546 Willow St Wes`r Barnstable,Ma 02668 West Barnstable,Ma: 02668 W. Barnstable, Ma 02668 -Earl Merrit / Suzanne Every Church St P.O.Box 566 fir. West Barnstable,Ma 02668 S. Dennis, Ma 02660 W.est.:Perish ,Church r - West Barnstable Fire Dist. Alexander Bowe Meetingho'Vae. Way !, Main St. 59 Gemini Dr West Barnstable,Ma 02668 West Barnstable,Ma 02668 W. Barnstable, Ma 02668 / Wilfred Taylor P.O James Crocker Bea.. Box 141 ow tr H141 - 378 Will St. 298 Willow St : W. Barnstable.Ma West Barnstable,Ma 02668 W. Barnstable, Ma 02668 02668 Glen Hartwell Stephen Eldredge 75 Cedar St . 140 Cedar St. ' WeA Barnstable, Ma 02668 W, Barnstable, Ma 02668 Town of Barnstable OF-THE o Regulatory"Services 'T ot"'t4 o 9ARNSTAB TLE • Thomas F. Geiler,Director : sAx STXSLe, - Z009 FEB I. '1659. Building Division . 2 €H 2: � s679. .� 31 �yF p Tom Perry,Building Commissioner 200.Main Street, 'Hyannis,MA 02601__,__ www,town.barnstable.ma.us 61hIs10 Office: 508-862-4038 Fax: .508-790-623C PERMIT# C�200 9D0 yy5 FEE: S SHED REGISTRATION 120 square feet or less Location of shed (ad ress) Village Property o er's name Telephone number /d ' 47 13010l �- Size,of Shed Map/Parcel # . SigiattlTe 0 Date Hyannis Main Street Waterfront Historic District? Old King's Highway Historic District Commission jurisdiction? Conservation Commission (signature is.required) Sign:off hours for Conservation 8:00-9:30 &3:30-4:30 PLEASE NOTE: IF YOU AR,WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION PEE. ' PLEASE SEE THE APPROPRTATE COMMISSION FOR DETAILS. THIS FORM MUST BE 'ACCOMPANIED BY A PLOT PLAN " Q-forms-shedreg REV:042506 ��` � �� c � � � ,HE,, Town of Barnstable Old King's I=Yighway Historic District Committee 9BAaMAM. 200 Main Street, Hyannis, Massachusetts 02601 (508) 862-4787. Fax (508) 862-4784 C.VRTIFICATE-OF EXEMPTION Application is hereby made,with four(4)complete sets,for the issuance of a Certificate of Exemption under Section 6 and 7 of Chapter 470,Acts and Resolves of Massachusetts, 1973,as amended,for proposed work as described.below and on,plans,drawings,or photographs accompanying this application: Date � el Address of Proposed work, Assessor's Map and lot# 130�0/ House# a2/3S Street UJayJ Village: GU �a�-E I.�,L. f'J7 f3 : O.R G d� This application is for an exemption of the proposed construction on the grounds that work: ❑ Will not be visible from-any way or public place Is within a category declared exempt by the Old Kings Highway Regional Historic District Comrnission ❑ Other Description of Proposed Work: ��� ,,�„`, /p /oZ, Agent or contractor(please print): Tel.no. -561-36 z Address- 16e x 230 &U 13 am-rIn le Owner(please print): 7o w h r" for In.r/n_z Tel no.. Owners mailing address: Signed,Owner/Contractor/Agent _ For Committee Use Only This Certificate is hereby Approved/Denied Date: `Committee Members Signatures: pC�lc�ll -CUBIC O 'L r EB 0 5 2009 TOWN OF BARNSTABLE HISTORIC PRESERVATION ,Any conditions of approval: Q:IGMD-GroupAOld Kings.Highway10KHNewApp0KH Exemption+form 0Tdoc r Town of Barnstable Old King's Highway Regional Historic District Committee CERTIFICATE OF APPROPRIATENESS SPEC SHEET Please submit 4 Copies Foundation Type:(Max. 18"exposed)(material-brick/cement,other) •C e M r-17 7 X IO G A Siding Type a1 material: [y e,6 Color. /�a�Urerr Chimney Material:,%/-Pt jp ,Ongd A 6e /1eA7Iyte/Color: Roof Material: (make&style) �,S p Q,j� j��C TU Y Q. Color: C Trim material (L A d Color: Roof Pitch: (7/12 minimum) Se.. G S le Window: (make/model) tiTOMe. material color Size(s): Door style and make: material (�� Color: G/,6itt Garage Door, Style Size Material Color Shutter Type/Material: Color: Gutter Type/Material: Color: Decks: material Size Color: Skylight,type/make/modeU: material Color: Size: Sign size: Type/Materials: Color: Fence Type(max 6')Style material: Color: Retaining wall: Material: Q Lighting,freestanding on building illuminating si Please provide samples of paint colors and manufacturers brochure of style of windows,doors, ge door PPNS��P��O� fences,lamp posts etc ADDITIONAL INFORMATION: Signed:,(plan preparer) print name tel. no. Dd'" A.- Location of application: Street no. Street AU L. Villagea� C.•1DocunientsandSettingsidecolli,�ILocalSettingslTemporarylnternetFilesiOLK/IOKHCertAppropriatenessoZdoc BOO GOB .� fill ys /oq to , n4eeti.ng ouse Farm I Z • . • . ' Qpp , 1 , , r , MEETINGHOUSE'FARM BASICS o ,r 2135 MEETINGHOUSE WAY �yw General ec+ Arch• +� 23 ACRES 4 REMAINING STRUCTUIZES •7� 't o � PRIVATE RESIDENCE � nv can FIN' v rn yc F`� PARTIAL UTILITIES Iry o - �NO pl3PTIc ISYlSTEM , d • OpLu •''�sts`Go ® ��O rn m o N; -cc o � �W . ¢ J�f � MCC OV m z CC 3:CD 0= 0 WHITE TRIM q o WOOD SHINGLES A. WHITE WOOD DOOR NORTH ELEVATION . MEETINGHOUSE FARM SASH HOUSE• •.k 8.21.07 101-4" CD o�YnJ • = _ �`), '`�O Q) mac\ V" Q �ICY ...... LD •� CD 4 _ WHITE TRIM all 'j{(n _ WOODSHINGLES -]PE t LIJ. - (p.�Z ih3^X r« fi�a ory� qudttl Tybas I�`Y ��!! m l O zzzz - .. I V"'3{A 5 x ` - r WHITEY£WOrOD DOOR '. • �• "zo � t E TH ELEVATION n jMLT INGHOUSE,FARM SM vH0'USE 8 21 07 :..:.:.::::::::::::: N.T. . . . S:� 12'-3° I, ASPHALT SHINGLES ZD SINGLE GLAZED, DOUBLE STRENGTH 0 WINDOW PANES o q WHITE TRIM WO D SHINGLES W2 0 51+C�1f,Ts S- o Co a o F-a o1-0 �w N� o m W EAST ELEVATION MEETINGHOUSE FARMS%�, o O ,rsl, SASH HOUSE 6'0 8.21.07 �," -G N.T.S._ { -311 , ASPHALT SHINGLES - WHITE TRIM T . A- I • ?1 r Ji 4 r - N .a 7...... 'e 0 a � • �r W. L WOOD SHINGLES WHITE WOOD'DOOR - ® ensm 93m L os O N rn - WEST,ELEVATION. � � �_•� :MEETINGHOUSE 'FARM a — �, ��SSH HOUSE �... RESIDENTIAL PROPERTY MAP NO. LOT NO. FIRE DISTRICT SUMMARY ' STREET Meetinghouse Way West Barnstable WB 73 LAND 130 / of BLDGS. ;{-:2. ,1 , OWNER TOTAL RECORD OF TRANSFER DATE BK PG I.R.S. REMARKS: LAND BLDGS. Conant, Fred D. 1� Bbith H. B TOTAL LAND 6-10-35 512 196 T O1 BLDGS. TOTAL - Oa� G� •r LAND BLDGS. TOTAL LAND BLDGS. TOTAL LAND BLDGS. TOTAL LAND � BLDGS. TOTAL LAND INTERIOR INSPECTED: - - BLDGS. DATE. _/S �� �6� y c, t c_--.__ _._._ _. TOTAL LAND ACREAGE COMPUTATIONS BLDGS. LAND TYPE # OF ACRES PRICE TOTAL DEPR. VALUE TOTAL HOUSE LOT LAND CLEARED FRONT BLDGS. REAR TOTAL WOODS&SPROUT FRONT LAND REAR a) BLDGS. WASTE FRONT TOTAL REAR LAND BLDGS. TOTAL LAND BLDGS. LOT COMPUTATIONS LAND FACTORS TOTAL FRONT DEPTH STREET PRICE DEPTH% FRONT FT. PRICE TOTAL DEPR. COR. INF. VALUE HILLY TOWN SEWER LAND ROUGH TOWN WATER BLDGS. HIGH GRAVEL RD. TOTAL LOW DIRT RD. LAND RI nr-R FOUNDATION BSMT. & ATTIC PLUMBING PRICING LAND COST ' ne.Well$ Fin. Bsmt.Area Bath Room r Base CJ BLDG. COST ... r one.Blk.Walls Bsmt.Rec. Room St. Shower Bath Bsmt. /�� PURCH. DATE nc. Slab Bsmt.Geroge O St. Shower Ext. Wells PURCH. PRICE. y. rick Walls Attic Fl.&Stairs Toilet Room Root {' RENT one Walls ✓ Fin.Attic " Z 17Two Fixt. Bath Floors ors INTERIOR FINISH Lavatory Extra smt. F. 45 1 2 3 Sink f Attie Plaster WaterClo. Extra �4u0 ?0ce/) :EXTERIOR WALLS Knotty Pine Water Only uble Siding Plywood No Plumbing Bsmt. Fin. �ngle Siding Plasterboard Int.Fin. `/ hingles ✓ TILING L� Inc. Blk. G F P Bath Fl. Heat 4- ©70 q , 9ce Brk.On Int.Layout Bath Fl.&Wain$. Auto Ht.Unit + yo �/ O Veneer Int.Cond. Bath Fl.&Walls Fireplace t I y&0 )m.Brk.On HEATING Toilet Rm.Fl. plumbing y Dlid Com.Brk. Hot Air Toilet Rm.Fl.&Weins. / Tiling Steam Toilet Rm.Fl. 8 Walls lanket Ins. Hot Water1343�/'^/ St. Shower ttof Ins. ' Air Cond. Tub Area Total , Floor Furn. ROOFING ZoNQ ✓ COMPUTATIONS ' eph.Shingle Pipeless Furn. /O S.F. ZZOQO lood Shingle t/ No Heat 3 S.F. /6 ,$U sbs. Shingle Oil Burner S.F. ' late Coal Stoker S.F. Ile Gas S F OUTBUILDINGS ROOF TYPE Electric t/ Flat S.F. 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 MEAS ,able U D ip Mansard FIREPLAC S. F. Pier Found. Floor Aim' lambrel Fireplace Stack / Wall Found. 0.H.Door LISTED FLOOR. Fireplace 3 Sgle.Sdg. Roll Roofing X one. LIGHTING Dble.Sdg. Shingle Roof arth No Elect. DATE Shingle Walls Plumbing ine 7 =./<— lardwood ROOMS � Cement Blk. Electric �sph.Tile Bsmt. 1st f TOTAL G / O Brick Int.Finish PRICED jingle 2nd 3rd FACTOR © 5 (� REPLACEMENT 32 7(S OCCUPANCY— CONSTRUCTION SIZE AREA CLASS AGE REMOD. COND. REPL. VAL. Phy.Dep. PHYS. VALUE Funct.Dep. ACTUAL VAL. 1 2 3 4 5 6 7 8 g 10 r �` ' TOTAL RESIDENTIAL PROPERTY MAP N '. '' LOT NO. FIRE DISTRICT sum STREET Mee-tinghGuse-Way West Barnsta�l@ RY / �J / A / / ��/ 73 LAND 37Sa:: OWNER //f`!A� � WB OI TOTAL s - LAND RECORD OF TRANSFER DATE BK PG I.R.S. REMARKS: BLDGS. • • ' eonallb, FredB TOTAL ! ZOO Conant, 'Frederic D. - 6-10-35 512 196' �- FLAND �o rn WET $ 12-31.-75 2282 213 �� 3 _ 3� Sa �'- t. olo esi TOTAL •/! .42 cJ, B rtlQL.c Avm. LAND - 0) BLDGS. TOTAL LAN D BLDGS. TOTAL LAND BLDGS. O1 TOTAL 'LAND INTERIOR INSPECTED: BLDGS. DATE: v ,a TOTAL LAND ACREAGE COMPUTATIONS BLDGS. LAND TYPE # OF ACRES PRICE TOTAL DEPR. VALUE 1 TOTAL HOUSE LOT- /p!t /� /ZcvoU /. n c!. -� /.? 6 n cl LAND CLEARED FRONT �ZLoa s, �Z /70G1pX90.Y / Z ti / /' ' BLDGS. REAR " _ TOTAL WOODS&SPROUT FRONT LAND REAR , l� I BLDGS. WASTE FRONT _ TOTAL REAR / ,/ f LAND l' BLDGS. TOTAL LAND 3 j So i 5 o BLDGS. LOT COMPUTATIONS LAND FACTORS TOTAL FRONT DEPTH STREET PRICE DEPTH % FRONT FT. PRICE TOTAL DEPR. COR. INF. VALUE HILLY TOWN SEWER LAND 3c> ROUGH TOWN WATER rn BLDGS. HIGH GRAVEL RD. TOTAL LOW DIRT RD. LAND .. LAND COST ' e.Wells Fin.Bsmt.Area Bath Room Base BLDG.COST _ :.Blk.Walls 1.9smt.Rac.Room St. Shower Bath Bsmt. PURCH. DATE � ' �• c.Slab Bsmt.Garage St. Shower Ext. Walls PURCH. PRICE. �. . k Walls Attic Fl.&Stairs Toilet Room Roof RENT e Wells Fin.Attic Two Fixt. Bath Floors !cf{ s INTERIOR FINISH lavatory Extra VVVY// t t. F f 2 3 Sink Attic /e'• /oa /Y rh r/4 Plaster Water Clo. Extra — XTERIOR WALLS Knotty Pine Water Only H9O ble Siding Plywood No Plumbing Bsmt.Fin. Ile Siding Plasterboard Int.Fin.Shingles TILING :. Blk. G F- P Bath Fl. Heat J) r s Brk.On Int.Layout Bath Fl.&Wains. Auto Ht.Unit Veneer Int.Cond. Bath Fl.&Walls Fireplace I. Brk.On HEATING- Toilet Rm.Fl. Plumbing d Com.Brk. Hot Air Toilet Rm.Fl.&Wains. /I�p4�n5 Steam Toilet Rm.Fl.&Walls Tiling iket Ins. Hot Water St. Shower I Ins. Air Cond. Tub Area Total �oA � Floor Furn. ROOFING COMPUTATIONS ' I h.Shingle Pipeless Furn. S.F. Id Shingle No Heat S.F. s.Shingle Oil Burner S. F. .2S :e Coal Stoker S.F. Gas S.F. OUTBUILDINGS ROOF TYPE Electric le Flat S.F. 1 2 3 4 5 .6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 MEASU Mansard FIREPLACES S.F. Pier Found. Floor nbrel Fireplace Stack Wall Found. 0.'H.Door LISTED ' FLOORS Fireplace Sgle.Sdg. Roll Roofing C. LIGHTING Dble.Sdg. Shingle Roof th No Elect. DATE e Shingle Walla Plumbing dwood ROOMS Cement Blk. Electric ih.Tile Bsmt. 1st TOTAL Brick Int. Finish PRICED gle 2nd 3rd FACTOR REPLACEMENT US� OCCUPANCY _ CONSTRUCTION SIZE AREA CLASS AGE REMOD. COND. REPL. VAL. Phy.Dep. PHYS. VALUE Funct.Dep. ACTUAL VAL. VLG. ds 7� /Cs•, t 6kee4l SF, (;IASs —,6�x/a0 'D v .Ci0 /v--,U J r U o v v 20 996c�• GAO j 2 •' Gloss/4j..d I-k6o OU .S.00 O SO / cv s G%Ass 4�a.d /oXf/o '/ao spa °a o SO u°o /o u o .00 o°V S0 ° u u o 00 96.00 Z 00 2V00 ZS 3 L L 3 3C v > s.Jed, sF2 ,� a2 7X a2 9 7 P3 d3 9 ZS 2734 9 s o B /� e �: .�� a9X35' 9 ��' s - " y," o Z _3Ny .3 3qs� i /•S�a' F� aZBX f/a /l ZO 8 7S 7y u v ZS 73 5-0 3 s' o S%!ed s F2• 9�/02 S So s� e ai 3 f2- 8X/o S S'� soe�►L s 6 -PROPERTY ADDRESS I I ZONING I DISTRICT CODE SP-OISTS.I DATE PRINTED I STATE I PCS I N8HD AR CLASS r.E`� KEY NO. 0275 MEETINGHOUSE WAY 05 RF 500 05wB 01/04/96 1091 JJ 34AC R130 014. LAND/OTH R Fl_atURES DESCIIIPIION ADJUSTMENT FACfOITS 70167 Bvma.,: 5..e D.ree.s vP UNIT ADJ'D.UNIT ACRES/UNITS VALUE Deser�pt�ar, C ON A N T, F R E D D E S T O F M A P— / CD 11; r.nmues LOCJYR.SPEC.CLASS ADJ. COND. PRICE PRICE L COMM, BLDG U x I = 100 * 59543.0 59543.00 1.00 595OU 3 CARDS IN ACCOUNT — FRAME BLDG X, _ * 02 _ 02 A 28080.0 28080.0 1.00 28100 f LOST N G'HSE x = * 19181.0 19181.00 1.00 19200 F MARKET 211900 G'HSE x J = * 17190.0 17190.00 1 .00 172JO F INCOME G'HSE x I = * 10530.0 10530.00 1 .00 10iJ0 F USE A G' HSE x I = * 2700.0 2700.00 1.00 2700 F APPRAISED VALUE p � D J A 393,600 4 PARCEL SUMMARY T S � LAND 218800 T 4 I 8LDGS 97100 0—IMPS 77700 M TOTAL 393600 F E I N CNST L N I DEED REFERENCEI Type DATE R-.,- PRIOR YEAR VALUE $e1Os Pric Book PagC MO. Vr,De LAND 218800 4 T T S BLDGS 174800 TOTAL 393600 3 BUILDING PERMIT *C O N A N T NURSERY. J Nu"" Dale Type Amount ................ LAND LAND—ADJ INC ME SE SP—BEDS FEATURES 8LD—ADJS UNITS 7770 59500 Class Coast. Total Voat Buil. No— Dosv. Units Unus Base Rate Aoj.Ra.e A , I Ago Dept. DOnO. CND. L.C. %R.G. Repl.Cost Ne- Adj.Rep..Veiue Stories Heignl Roo ad Rme Batna •Fig. PeRywall Fee. 87C 001 000 001 40 60 34 45 100 45 59500 26800 1 .0 1 1 DeSCrtption Rate Square Fee, Real.Cost MKT.INDEX: 1.00 IMP.BY/DATE: / SCALE: ELEMENTS CODE CONSTRUCTION DETAIL i BAS 100 .00 1 REA STRUCTURE CNST GP- f STYLE 35COMMERCIAL 0.0 ___ _ _ ESLGN ADJMT JO 01 EkTcR.41ALLS 00 0.0 EAT7AC TY ------------------0-0 j INTER.FIIVISH 00 ------------------ 0.0 1NTER.LtiYO0T 00 0.0 1 INTCR.OUALTY 00 ------------------0.0 \ LOOR $TR C UT 00 -------------------Ij.O_ p FLOORpCOVER-- 00 -------- 0.0 - C Total Areas Au _ Base_ 1 JOF" 1 1 v Pc---- _00 ------------------ Go T BUILDING DIMENSIONS EU-CTRICXC 00 __________________ CT 0 T A FOUN _DATION 00 0.0 -------------- - --- ---------------------- --------------- --- ---------------------- L LAND TOTAL MARKET PARCEL AREA VARIANCE +0 +0 STANDARD [ ] [R130 014 . ] LOC10275 MEETINGHOUSE WAY CTY105 TDS] 500 WB KEY] 70167 ----MAILING ADDRESS------- PCA] 1091 PCS] 00 YR] 00 PARENT] 0 SCANDLEN, JOHN & MAP] AREA384AC JV] MTG10000 NICKULA, WILLIAM SP1] SP21 SP31 66 BLANID RD UT11 UT21 6 . 71 SQ FT] 1222 .OSTERVILLE MA 02655 AYB11825 EYB11970 OBS] CONST] 0000 LAND 218800 IMP 97100 OTHER 77700 ----LEGAL DESCRIPTION---- TRUE MKT 393600 REA CLASSIFIED #LAND 1 218, 800 ASD LND 218800 ASD IMP 97100 ASD OTH 77700 #BLDG (S) -CARD-1 1 70, 300 DESCRIPTION TAX YR CURRENT EXEMPT TAXABLE #BLDG (S) -CARD-2 1 26, 800 TAX EXEMPT #OTHER FEATURE 1 2, 700 RESIDENT' L 318600 318600 318600 #OTHER FEATURE 3 75, 000 OPEN SPACE #PL 2135 MEETINGHOUSE WAY COMMERCIAL 75000 75000 75000 #RR 1013 0900 INDUSTRIAL EXEMPTIONS SALE] 03/97 PRICE] 1 ORB] 10666086 AFD] I JT N LAST ACTIVITY] 06/12/97 PCR] Y i z R130 014 . A P P R A I S A L D A T A KEY 70167 SCANDLEN, JOHN & LAND BLD/FEATURES BUILDINGS NUMBER ZN/FL=RF 218, 800 77, 700 97, 100 2 A-COST 393 , 600 B-MKT 211, 900 BY 00/ BY /00 C-INCOME PCA=1091 PCS=00 SIZE= 1222 JUST-VAL 393 , 600 LEV=500 CONST-C 0 ----COMPARISON TO CONTROL AREA 84AC -- --MAY NOT BE COMPARABLE-- NEIGHBORHOOD 84AC WEST BARNSTABLE PARCEL CONTROL AREA TREND STANDARD . 101 10 LAND-TYPE 2188001 LAND-MEAN +001 3936001 100293 IMPROVED-MEAN -30 250-. ] FRONT-FT 1] 100 DEPTH/ACRES TABLE 02 1000] LOCATION-ADJ APPLY-VAL-STAT 1 LNR] LAND LFT/IMP]ADJS/SB/FEAT STR] STRUCTURE ARR]AREA-MEASUREMENTS NOR] NOTES COM] MARKET INC] INCOME PMR] PERMITS GRR] GRAPHIC FUNCTION- [ ] STRUCTURE-CARD NO- [0 0 0] DATA- [ ] XMT [?] R130 014 . P E R M I T [PMT] ACTION [R] CARD [000] KEY 70167 000000001 PERMIT-NO MO YR TYPE VALUE CK-BY MO YR oCMP NEW/DEMO COMMENT Assessor's Office(1st floor) Map Parcel l/ Permit# ���9 Conservation Office(4th floor)(8:30-9:30/1:00- 2:00) /� (9} Date Issued 2- — " 9 7— Board of Health(3rd floor)(8:15 -9:30/ 1:00-4:45) JL�� TEM MUST BE Engineering Dept.(3rd floor) House# Z 3 r STAl I E DANCE®N DE AND 4 Planning Dept.(1st floor/School Admin. Bldg.) w Definitive Plan A Planning Board /� � 19 W, IONS TOWN OF BARNSTABLE. Building Permit Applicatio Project Street Address / Village srl- Owner //fr1J Address lfCX�a,2 Y, L� Telephone Permit Request 4P First Floor square feet Second Floor square feet Estimated Project Cost $ �Q U r Zoning District Flood Plain Water Protection Lot Size Grandfathered ? Zoning Board of Appeals Authorization pp Recorded R Current Use �i� S' T (W-7 10 Alo, Proposed Use Construction Type cr c...� Commercial Residential - Dwelling Type: Single Family Two Family Multi-Family Age of Existing Structure Basement Type: Finished Historic House Unfinished Old King's Highway l/ Number of Baths ��.. No.of Bedrooms l Total Room Count(not including baths) First Floor Heat Type and Fuel Central Air Fireplaces Garage: Detached ,�� Other Detached Structures: Pool Attached Barn None Sheds Other Builder Information �J / Name G1�/' /�L C Telephone Number / ,f Z !9 Z - I� Address License# ('b Z Z Y Home Improvement Contractor# fL Worker's Compensation# 9.e. NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SNOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE / zcz Z BU I ,OLLOWING REASON(S) FOR OFFICIAL USE ONLY ,r PERMIT NO. r " DATE ISSUED MAP/PARCEL NO. � ADDRESS VILLAGE r ° OWNER DATE OF INSPECTION: FOUNDATION.-. - ' c FRAME ' INSULATION ' FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: - ROLJGH .FINAL _ GAS: " ROUGH FINAL FINAL BUIL� O DATE CLOSER,QJ A ASSOCIATIO N MO. n c - ' � ✓lee 'Vaninzoowr� o���aaaac>l�eet� . 3HAP,T IE5T H- ::TK 7 _.. i4l.�Fr' _ — ��• rtti: '!rthdate 2)�118/19:" i CARRY 9 VICKiJi,AS BOX 199 WEST HUNNISPORT; 0i67 . 6,7, t "ldl NTR , bpi IVIDUAL: " '. •��ExRication�06/1.8/48 LARRY EdULAS. } 7f y�,D Nickd-F MINIS111tATOR O BOx ilsst Hyannis NA 0261 d 2 � A i 1 (21 CC TheTown of Barnstable �� Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crosses Fax: 508-790-6230 Building Commiss: 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 preexisting 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: G Est.Cost Address of Work:— Owner's Name v� `�`� Date of Permit Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law _Job under S1,000. 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 H"ROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply fora ermit as the agent of the owner. C l Date Contractor Name Registration No. Application to �„ 0> OPENS�``pN�• ^o . E� Old,King♦s Highway Regional.Historic District.Committee 9 7 2.'5`0 ih.the Town of Barnstable for a CERTIFICATE OF APPROPRIATENESS Application is hereby made, id triplicate, for the issuance of a Certificate of 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 Constru tion: New Building ❑ Addition...*' Alter tion Indicate type of buildin House ❑ Gari e ❑ Commerc al Other g 2. Exterior Painting: 3. Signs or Billboards: ❑ New sign ❑ Existing sign ❑ Repainting existing sign 4.. Structure: Q. Fence ❑ Wall ❑ Flagpole. ❑ Other (Please read other side for explanation and requirements). TYPE OR PRINT LEGIBLY DATE ADDRESS OF PROPOSED WORK -ASSESSORS MAP N0. a Z. 4 OWNER 12nG-?9 / 1%Jr'_1-erV 1/11� ASSESSORS LOT NO. O/ 2 HOME ADDRESS �G ��� SQ� -�Gf'1 �R//'�f7�i�J�TEL. NO. FULL NAMES'AND ADDRESSES OF ABUTTING OWNERS. Include name of adjacent property owners across any public street or way. (Attach.additional sheet if necessary). 64 AGENT OR CONTRACTOR "�v TEL. N0. J 4 Z 6 Z � /� ADDRESS ClK 5,1 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, i.f.necessary). LF D t�ll� ..J (! - Signed ner-Contractor-Agent Space below line for Committee use. Rec�iv%by H:D:C-..- 49 2 I] n `=D ate �' ;The Certificate is hereby k,4,4,,a Date l 9 Tin Z M Aavt4 By Approved Q IMPORT If Certi Icate is approved, approval is subject to the 10 day appeal period provided in the Act. J Town of Barnstable Old King's Highway Historic District Committee SPEC SHEET FOUNDATION SIDING TYPE COLOR CHIMNEY TYPE COLOR I ROOF MATERIAL G COLOR PITCH WINDOW SIZE TRIM COLOR DOORS COLOR SHUTTERS COLOR GUTTERS RpC DECK. GARAC!E DOORS COLOR SIGNS COLORS 'FENCE COLOR NOTES: Fill.out completely, including measurements and materials/colors to be used. Three copies of this form are required for submittal of an application, along with three copies each of the plot plan, landscape plan and elevation plans, when applicable. Site plan should show all structures on the lot to scale., SPECSHT Depurtnient of hu ustrial Accidents 1 ;:w Office of/nyesUgat/ons ti �;�` hO// f1'ashinwn,n Street Bustun. Afa.vx. 02111 ' Workers' Compensation Insurance Affidavit _ �..��,._. .... __ ._._..... --.-'.^•' .. ._mot._..•�.a�w.+....e.....,wa..-r.r. ...y..:.....�-•—. - �....—...�. �nlicant tntormahon Please PRINT le�Ly t = - name t. city r t ' I am a homeowner performing all work myself. 1 am a sole proprietor and have no one working in any capacity _ L..:.:�i-•=7��`4t .+.---. �-+5"a--+�..!7�r.T"•��rYTr;!ti+^."'�a��w�p?�-�,"t.r .. ,�.��a:._._.-.•.e. -- �rl�r�^r"`n'•?�;'�'!!�t.rr.•.....ie'� . -! am an employer providing workers' compensation for my employees working on this job. co"Inattv name: MI S��G /,/�f�G f� nhnnc 0 � in�onince co CJ I�am a sole propri+ or, general contractor omeowner(circle one)and have hired the contractors listed below who have the following workers compensation polices: cottivin n►me: _.e � 1r s 6 S w� ins urance co. ( C�5/ayJ �C�t' 120lievtl J Q .-.. ,..:.n::: ��r��m.-e—,->.•:�T•rZ• e— �}:-� •-r-•ras -7I"ifs-it•/nt7.'yi''Y" '."'•f�S�7�c'''.*.:r� �-�y.'.R '^y'�""�.r.s comlam name �/ P a address: / • v city: c11hone#• 12 wfinsurance co �rj'?�? nolicL# _ :Attach additional sheet•if neeessary� ,;, ;i,�'`^'�`"=sy ;= =:_" ----- Fuilurc to secure coverage as required under Section 25A of I11GL ou can lead to the imposition of criminal penalties of a fine up to SI.SOU.UU and/or one.cars'imprisonment as well as civil penalties in the form of it STOP NVORK ORDER and a fine of 5100.00 a day against me. 1 understand that a cope of this statement may be forwarded to the office of Investigations of the DIA for coverage verification. 1 do hereby certifi•under tlrc parrs a •tallies ojprrjun tlr the in rmation provided above is true and correct. Sienaturc Date _ Print name /'rt� Cam"eJ �o'� Phone N ofliciai use onh• do not write in this area to be compacted by city or town official city or town: permitilicense# riBuilding Department Licensing Board I] check if immediate response is require) �Seleetmen's Office [jIlcalth Department contact person: phone#; nOther i reviled;ros Pt.a t DEMOLITION PERMIT NOTE: OKH District approval required prior to issuance of permit for propertylocated in the Historic District (north of the Mid Cape Highway) In Hyannis - Check to see if it's included in the Hyannis Historic Waterfront District, if so, it needs approval from the Historic District. 2 Sign-Off from Historic Preservation (this is required no matter where house is located) . 6 y� D Specify on permit where demolition debris is to be disposed of. Certification that the following utilities are shut off: Gas Electric Water If on town sewer- sign off from Engineering that sewer has been capped If septic system - no certification required / Worker's Comp form must be submitted if more than one person will be involved in the work. Fee - (Minimum) NOTE REGARDING DUMPSTERS: (527-CMR-34) TELL APPLICANT THAT A DUMPSTER OF 6 YARDS CAPACITY OR LARGER REQUIRES A PERMIT FROM THE APPROPRIATE FIRE DEPT. g4onns-PERMITS 1 Rev 6/2/98 �—fl ��� / �� / �� j �� ��P�/J Tt7 l�f�f �cc� �� � G` ��� c ? � 127 Yarmouth, COLONIAL, .So. Yarmouth,arniouth,M MA 02664 , 1-800-548-8000 G A S C 0 . M P A N Y Fax"5 08-394--2'564 August 10, 1998 Mr. Larry Nickulas Nickulas Building Company P. O-Box 507 W. Barnstable, MA 02668 re: Route 149;West Barnstable Greenhouses near corner of Cedar Street To Whom It May Concern, t _ This letter is to,confirm that there are no underground•natural gas facilities to the above referenced;property. This was confirmed by our representative on August 7, 1998. Sincerely, Bonnie Figueroa - Distribution Department f yn a '• °qe 142�jY�4 � 2VCo� ho i�, U a^O Q • +t° Al't G `w G,, �i. hp�q' 4FiInNOy� w N �a+a• 4 N ' ti� �� . +94v`� Qly ��� � w � A � n � •f•+•'�• a�' ���� n y T tk JA `�Ar,��;' M `�,`.. � Epp o`'y � 4. �'• VZ,e y o n 4 � ° .�+e► p dv�+° � I I I I h C p p(.i1.//•AL .Lf 'Y•yl,LP•fs/Y •pf•LI/ y� ./s'st v q: -. } °o• .io sa ss`cots it ' «.s9s 8/fTo.iss At '/tvs w " o v { .3r. n pi 64 Ar '� � r� •� is �� v • � �{ �v ao• ••,v- .. tir.l � � to y g a � r y � v Ot �4twf•�9 'y.� moo. ^ � ' ' � sso suaRs t o Z n y c+ * ' •� ` r$ �'�t brivN a �� c V 1. i��• 0 ' q V .� .Nt 11'.� so.s7• ,v >M h ti h ti 5 V CN .ltwo s to.,v.rJ S k '°•��. b . �l;y, / '.�� —ter; ts it- fj ri e M C p Z � c a �• it, IA O ° ,e` 7 r4 n tl r F � AJS I i — •.►.fir/`�.— •►��►_� � _ � :�! I _. ter— ��►„_`mow�.� _ �1�* - I w �, ��'r�_r�- �I����_ _. �►._ _ o`-- Lam' r -���."� ��II�II I ,lugpl'.. i�.�ll�l Iilllla ��. f • to �� rfrw.,.. • .. iI �`/� I �" i !� y, s . I i i 1 �Ss rc{. c...'• � I ,_�, I �-��_ ALI y" qq�! .S♦:1.•,�d•�i f'.X of f � r'��L ��+�. '4 -��1 k�� s .y 4 91a F ,r a i ' ► t -it fix: if J I 'y mow• .i' '' �f✓ a 1 {� t�.`t�f' �� �•�' � fir-•—.L,7'S"� '-•K�a- ^.•�t.� +S +r. �: �•'�6 iEL4 �fi7�. �„��! f I I - - --p c f -p EA ,�'�A � 3 \ 2' •�/�if'E.BY CERT/�Y T.�,9T Tf//S PLAiV N.4S BED �R 9 GE 7f/ T//E MULES ANL> /�EGU�AT/D/V's `� ---_.• OF T.z/E k'E�IST.ER's OF DE�"As OF 77125 CD�1/'JDiVh��.4LTs�f pJI °� a k 27, -co, �. � � ~�. - . ,deDf�ssiDN.9G G•�IIi(/D SU,e1�y h' CGU,yP ai' 3 - ' cA I, . „� � - • � '�-s� N -� _ FEE!/sTi�Y USE c�iS/GY S,B• a�. � e l/ � I � � C7- Q ' z IN • ., D .fit ',� .►� , r /VOTE'- L O T No, 2,4 l 3 ' // ` OD tD /iV f'L,4AI BODk 33Z f'4a,, 22 �� s. ,GOT N©. 2.1 /S CGA/M�o BY 11/, N/G��11.9� �- -G67, 992 S.!� list 9 A •2- DR/ NP 0 � I-e -sue ✓ ot P c N _ P . q� , D D y G i 1 D I ,c�,_ �y - ►� k1 2� Ago syo� o . 0 i Q Ir 1�t/ORkSf/DP ll'' ' 0 5 FND• ; � 322; t� r S l�ERE,By CE/c' hT�4T W 'PE✓YTYL/r ./Es .5W4h/Al oA/ 7.V/s/�Y $ �I E L A//E LIVIZIAla :XX5'T//Vlf'S, A11/.D FLAN A.PE T// / S 4 :7S AND J'✓.9 .S Sh/DI-t/JV- A f'f yf/dS"5.Dry AU*94/G Tye 4/,vas sT,eE Y .a , q b e, oe s .4L1ee.4Dy 05TA8G�.S.4�Ehs .4i✓v Tyar � Oro P.P/l/.97� 5T,E' �s yv Y � � 1 t► ,, ES Q/v!s ^/o,G'E.rfsT7M5 oyz/rVO.es"�ia aR FOR .� tK El✓ A 5 ARE S11V)iI t/" I Y� A iV yr/ y � A, S � .l:�zV,4256-s/D.V.9G 1-4,VoO s .e �?' � �� o� h � y h � � \ �t✓ 2 r PEEP/METER RGAN Y /- Z-41VL) • PA o9 y� fL ly "� rj s /N N. � + 1 ._._ 27 j P 4�W C--Aoe 7 1 ..+..u.aw�..a•,.rM..»�:,....n ,*.._� ._. s .. .. a -..... n,., a,...��+ ..vr�yr c..a.s ,. _.� .,�......e.._........._.....r�+...w.+'M+"'r" .-,. � „ .-.....ter,- f t I 4 ... a`' j I i