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0011 PETER BLOSSOM LANE
i n f i NO. 13Q 1/3 O!U MAMIOusAEMLTE �I L w. av i -a� � z �. _ _ _ _ � - - _ l �_._-- _� G�� � 0 / `. �"— __ . _ s r Town of Barnstable *Permit# a -q3 Regulatory Serv' a �ee 6 months from issue date 3 9. Richard V.Scali,Director a. /r/�� 9 O� Building Division APR p 5 2017 �9A Tom Perry,CBO,Building iop 200 Main Street,Hyannis,MA www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Map/parcel Number U Not Valid ipilhoutRedX-Press Imprint Property Address I I Fe-'+fV 19 l0 SJ 011 /V • �/p /1/r/rA� �� ` [(Residential Value of Work$ U 001 ©0 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address '��'� c NAJI'4 YA Yy y 4 e / l'�tt/1 41/aoja01 z B•4,TNAr,4jle, 7.4 0a64dop Contractor's Name fA H ej j??C COlroy c Telephone Number �rD a- 6 Y t -9/r V y Home Improvement Contractor License#(if applicable) /00 BYO Email: ,)/' 4 1.04 11 U e.!4 /f S b Construction Supervisor's License#(if applicable) li G?6 2 l 4W( orkman's Compensation Insurance Check one: ❑ I am a sole proprietor H �am the Homeowner /have Worker's Compensation Insurance P Insurance Company Name 4 JUAgo �Z_AIJ Workman's Comp.Policy# n 'L JV C 77 r3 a� Copy of Insurance Compliance Certificate must accompany each permit - Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side (Replacement Windows/doors/sliders.U-Value d.R 6 (maximum.32)#of windows `_rh.e1,, ss i�L,4k B #of doors: / f10or.?1 ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. *"Noti Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: C:\Users\Decollik\AppData\LocalUvlicrosoft\Windows\Temporary Internet Files\Content.Outlook\?PIOIDHR\EXPRESS.doc Revised 040215 Page 7 of 7 Capizzi Home Improvement Inc. Specifications and Estimates STATE OF MASSACHUSETTS LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT OCA���Lr"I �L f��•t, � �i s7 J UWE, /h��cRy�-7 , OWN THE PROPERTY LOCATED AT /( P � J`/V IN W-1 49AP7""l- , MASSACHUSETTS. I HAVE AUTHORIZED CAPIZZI HOME IMPROVEMENT TO ACT AS MY AGENT TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. I GIVE MY PERMISSION TO LESSEE TO APPLY FOR A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS STATE BUILDING CODE. SIGNATURE OF OWNER: ✓�y � /d , „� OWNER'S ADDRESS: OWNER'S TELEPHONE: LESSEE'S SIGNATURE: LESSEE'S ADDRESS: LESSEE'S TELEPHONE: APLLICANT'S SIGNATURE: APPLICANT'S ADDRESS: 1645 Newtown Rd., Cotuit, MA 02635 APPLICANT'S TELEPHONE: 508-428-9518 RESPONSIBLE OFFICER: RESPONSIBLE OFFICER ADDRESS: RESPONSIBLE OFFICER TELEPHONE: I DATE(MMIDDNYM CERTIFICATE OF LIABILITY INSURANCE 12130/30/20/62016 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 WANED,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 endorseme s. CONTACT Rogers and GrayProcessing PRODUCER NAME ROGERS&GRAY INSURANCE AGENCY INC PHONE 508 398-7980 AD a/ No: 0 E-MDRESS:AIL mail@ g ro ers ra .cam 434 ROUTE 134 INSU S AFFORDING COVERAGE NAIC# SOUTH DENNIS MA 02660 INSURERA: AMGUARD INSURANCE CO 42390 INSURED INSURER B: CAPIZZI HOME IMPROVEMENT INC INSURERC: INSURER D: 1645 NEWTOWN ROAD INSURER E: COTUIT MA 02635 INSURERF: COVERAGES CERTIFICATE NUMBER: 114654 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. ADDL SUER POLICY EFF POLICY EXP LIMITS INSR TYPE OF INSURANCE POLICYNUMBER MM/DD MMIDD LTR COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR PREMISES(Ea o $ MED EXP oneperson) $ N/A PERSONAL&ADVINJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY ElPRO-JET LOC PRODUCTS-COMP/OP AGG $ OTHER: COMBINED SINGLE LIMIT $ AUTOMOBILE LIABILITY EaacGde t BODILY INJURY(Per person) $ ANY AUTO ALL OWNED SCHEDULED N/A BODILY INJURY(Per accident) $ AUTOS NON--OWNED PROPER DAMAGE $ HIREDAUTOS AUTOS P acadent $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE N/A AGGREGATE $ $ DIED RETENTION$ WORKERS COMPENSATION X PER ETH AND EMPLOYERS'LIABILITY YIN E.L.EACH ACCIDENT $ 1,000,000 ANYPROPRI ETOR/PARTN ER/EJ(ECUTNE NA 16 2/25/2017 A OFFICER/MEMBEREXCLUDED9 WA 2/25/20 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 (Mandatory In NH) If yes,describe under E.L.DISEASE-POLICY LIMIT .$ 1,000,000 DESCRIPTION OF OPERATIONS below N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be 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/lwd/workers-mmpensationAnvestlgations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Town of Barnstable 200 Main Street AUTHORRED REPRESENTATIVE C Hyannis MA 02601 pan IIB M.Cr ey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 26(2014101) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents - Office of Investigations _ 600 Washington Street - Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): CAPIZZI HOME IMPROVEMENT INC Address: 1645 NEWTOWN ROAD City/State/Zip: COTUIT , MA 02635 Phone #:' 508-428-9518 Are you an employer? Check the appropriate box: Type of project(required): 1. ✓ I am a employer with 40+ 4. I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. New construction 2. I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have g. Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp. insurance comp. insurance.1 required.] 5. We are a corporation and its 10. Electrical repairs or additions 3. I am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12. Roof repairs insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13. -, Other —D O OV comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: AMGUARD INSURANCE COMPANY . 2 Policy#or Self-ins. Lic.#: R2WC527-00 Expiration Date: 12/25/2017 Job Site Address: 11 ���ed lOoJ o�'rl. j..QNR City/State/Zip: Zd ` '8AKNf'f4O k. fl Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi u d r the pains andpenalties ofperjury that the information provided above is true and correct. Signature: Date: Phone#: 508-428-9518 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-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships (LLP)with no employees other than the members or,partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. jThe Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax# 617-727-7749 www.mass.gov/dia Massachusetts Department of Public Safety aP Board of Building Regulations and Standards License: CS-076261 Construction Supervisor C JAMES MCCORMACK 73 FEARING HILL ROAD WEST WAREHAM MA 02576 _ Expiration: ! Commissioner 11/13/2017 Q e� 1(o�Arirrv�luCr�ll�r�C %(II. 'nr�llJe� License or registration valid for individual use only _Office of Consumer Affairs&Business Regul tion before the expiration date. If found return to: IL Office of Consumer Affairs and Business Regulation ME IMPROVEMENT CONTRACTOR 10 Park Plaza-Suite 5170 ` ��,r Registration:. 100740. Type; Boston,MA 02116 -'� Expiration,: ai%2312018 Supplement Can CAPIZZI HOME IMPROVEMENT,INC. JAMES MCCORMACK 1645 Newton Rd. No valid without signature Cotuit,MA 02635 Undersecretary .ti TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map �8 Parcel d 0/ T ' � �� R� TALE Application # � I j ;, IF lth Division �'+.► ' a`� ',°� f:. Date Issued " . �/ Hea Conservation Division Application Fee Planning Dept. r - �� Permit Fee L5 Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address x Village Owner Address_ Telephone Permit Request —^w�R� Square feet: 1 st floor: existing proposed 2nd floor: existing . proposed Total new Zoning District Flood Plain Groundwater Overlay ao Project Valuation 3:A00. Construction Type Lot Size / Grandfathered: 0 Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family d Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑ Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing Z new Half: existing new Number of Bedrooms: 3 existing _new Total Room Count (not including baths): existing It- new First Floor Room Count Heat Type and Fuel: ff'Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing O 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 �co g34%y Address %A 1 License # S c. Home Improvement Contractor# \> Za Email Worker's Compensation # l.o%,%3 v yIck ALL CONSTRUCTION'DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE� J S� FOR OFFICIAL USE ONLY a APPLICATION# DATE ISSUED MAP/PARCEL N0. ADDRESS VILLAGE OWNER • I DATE OF INSPECTION: 3 � Y FOUNDATION � - s FRAME . n INSULATION FIREPLACE tii F ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL 7- FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. Massachuseft Deportment of oubiioSafety -�` Board of Build Ing Regartawns anC,Slandatcis ,y � f'+tn.truin,n:'iper�t,�Y Spr�;ialt� ;a License;CSSL-1027MS s.t� nLt_1 C- D MC1Ni►,, NXy `- 39 SIASCONSE >Jii 14 SAGAMORE B ' C$ 2 J.Lr— tt its" ExpirA tort Commi stoner 08/19/2016 r �A Ofliec or Consumer Affairs&Business Regulation License or registration valid(or ndividui use only ME IMPROVEMENT CONTRACTO beforethe expiration date, If found return to: ` F evistration: 17125,1_. Type; Office of Consumer Affairs and Business Regulation zp rattori: ;3f112016. Part h P 10 Park Plaza-Suite 5170 Boston,MA 02116 CON-SERVE ENERGY CONOR MCINERNEY 376 ROUTE,130 SUITE C SANDWICH,MA 02563. Undcrsec retary Not valid without signature PROGRESS REPORT RESPONSIBLE EMPLOYEE NAME TASK i DATE COMPLETE 1 " 1 nrrscxn t a t Inc Lm rrsuyu any I no LICK t trtv.;a t e nuL-Urx. IMPORTANT:If the certificate holder is an ADDITIONAL INSUff l),the policy(les)must be endorsed.if SUBROGATION IS WAIVED,subject to the tems and conditions of the policy,certain policies may require quire an endorsement.A statement on this certificate does not confer rights to the certificate holder In lieu of such endorsements. PRODUCER CONTACT NAME CS8&IWORKCOMPONE PHONE FAX A/C,No,Ext: AIC,No PO BOX 946580 EMAIL ADDRESS Maitland,FL 32794-6680 INSURERS AFFORDING COVERAGE NAIC# 1-877-724-2669 INSURER A: Continental Casualty Company 20443 INSURED INSURER 8: CONSERVISION ENERGY INSURE'C: 376 ROUTE 130 INSURER D' SUjTE C INSURER F. SANDWICH,MA 02563 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BJELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDINGANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE1AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HA BEEN REDUCED BY PAID CLAIMS. LTRR TYPE OF KSURANCE nap D POLICY NUMBE9 T P NMD M P OLICp� LIMITS A GENERAL LIABILITY Y 6011316335 03111/15 03111116 EACH OCCURRENCE 1.000.000 COMMERCIAL GENERAL LIABILITY' PR W:S(E.a ors r 300,000 CLAIMS-MADE ®OCCUR MED EXP(Any am person) S 10,000 PERSONAL 6 ADV NAM 1,000,000 GENERAL AGGREGATE $ 2.000.000 GEN'L AGGREGATE LIMIT APPLIES PER: PRoaucTs-compmp ADCs = 2,000,000 POLICY J /X LOC A AUTON0131LE UABDITY 6011316336 03111 H 5 03/11/16 (Ea acciideert� UMrr SINGLE s 1,000,000 ANY AUTO BODILY INJURY(Per person) $ AUTOS OWNED �/ SCHEDULED BODILY NJURY(Per accident) PROPERTY HIREDAUTOS /� AUTO OS ED (PeracddentDAMAGE $ A UMBRELLALIAB X OCCUR 6011316352 03111/16 03/11/16 EACH OCCURRENCE 2,000,000 EXCESS CLAIMS-MADE AGGREGATE Z0801008 ED X RETENTION L 10,000 $ WORKERSA AND U PLO Uu Balm YIN 6011316349 03111/15 03H 1116 X1 TaRy UMrrS Et ANY PRoPREToR)PARTNERIEX ajnvE OFnCERMEM�°I NIA EL.EACH ACGOFJYi = 500,000 (Mandatory In UK) EL DISEASE-EA EMPLOYEE 500,000 tl yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT = 500,QO0 OTHER I TORY LIMITS I I ER EL EACH ACCIDENT = EL.DISEASE-EA EMPLOYEE Is E.L.DISEASE-POLICY U urr !UI IS required) Certificate Holder Is added as an additional Insured as prodded in the blanket additional Insured endorsement as it pertains to work being performed by named Insured under written contract4 INCLUDES PRIMARY AND NON-CONTRIBUTORY CERTIFICATE HOLDER CANCELLATION Rise Engineering SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1341 Elmwood Ave Cranston,R102910 AUTHORUXD REPRESENTATIVE ®1988-2010 ACORD CORPORATION.All rights reserved. ACORD 2.6(3010105) The ACORD name and loIgo are registered marks of ACORD ConsorVision Energy le o to 0 o e to 0 EMPLOYEE: T TO: PURPOSE: DEPARTMENT: Weatherizabon/Audit DATE SUBMITTED: 2/27/2015 DATE EXPENSE TYPE ESTABLISHMENT LOCATION COST NOTES 2/10/2015 weatherizalion Home Depot Hyannis 34.47 2/12/2015 Audit Aubuchon Sandwich 9.02 Batts 9v 2 pack 2/10/2015 Westaherization Home depot Hyannis 260.29 Stock 2/11/2015 WEatherization Home Depot Hyannis 136.05 Kids Room 2116/2015 WEatherization Aubuchon Sandwich 8.49 Respiater for John 2/20/2015 Conors car Ace Hardware Sa amore 20.18 Tow rope 2/23/2015 Audit Harwich Paint Harwich 6.49 Light bulb for audit customer 2/23/2015 WEatherization Aubuchon Sandwich 33.98 Flashing stock 2/12/2015 WEatherization Aubuchon Sandwich 24.42 Flashing stock TOTAL DUE SIGNATURE: APPROVED: DATE: DATE: • - • �1Q•�f�o+u1Ly� •• ' �n� -- -- �l The Com ottwealth of Massachusetts Depa i ent of Industrial Accidents Oi�9ce of Investigations 610 Washington Street oston,MA 02111 www nrassgov/dia Workers' Compensation Insurance Atlidavit: Builders/Contractors/Electricians/Plumbers A He Inform d Please Print L egibN Name(Eimiaw/organizauowbdi iduat): Cons rVision Energy Inc Address: 378 Route 130 City/state/Zip: SAndvAch, MA 02563 Phone#: 508-833-8384 Are you at employer?Check the appropriate bo i i.ElI am a employer with 6 4. ❑ I am a general contractor and I Type of pro jteet(required): employees(bill and/or part-time).' va hired the sub-contractors 6• ❑New construction 2.❑ 1 am a sole proprietor or partner 1 on the attached sheet, 7. ❑Remodeling ship and have no employees Tttase sub-contractors have g, ❑Demolition working forme is any capacity. loyees and have workers' [No workers'comp. insurance comp•insurance) 9. ❑Building addition required] 5• ❑ e are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work o f'ican have exercised their I l. Phtmb'❑ mg repairs or additions myself.[No workers'comp, Hi t of exemption per MOIL insurance required.)t c. 152,§10),and we have no 12.[]Roofrepairs 3a❑ I am a homeowner acting as a em iployees.[No workers' 13.©Other Weatherization general contractor(refer to#4) coMp.insurance required] 'AnY aMhcM that deb box N i must also till out the swdoo bola stowing they workes'comps fey information. t Homeowners who submit this&Mdsvit Indicating they ate doing work and then hire outside contnncten Inlet submit a now affidavit indicating such t VIOY etore that check this box mho attached an 6 the o>nl sheet s the tisane of the and sate wbether or not thOw entitin have t asptoyees if the site-ooeascton have ettooYees.they a� t*w worker'comb•Doha number I are an employer that is p ovidLtg tuorkers'compe n bttsrronrt or inforeradont, I f "'Y employers. Below&flu Polley andJob site Insurance Company Name: CSMWORKCOMPONE Policy#or Self-ins. Lic.#: 6011316349 Expiration pate; 3-11-2016 Job Site Address: CiWState/Zip: Attach a copy of the workers'compensation policy d eclaration page(showing the policy number and expiratiom date). Failure to secure coverage as required under Section 25 k of MOIL c. 152 can lead to the imposition of criminal fine up to$1,500.00 and/or one-year imprisonment,as ell as civil penalties of i of up to$250.00 a day against the violuor. Be advised t a copy of this asta in may be forwardedT0to Office of ORDER d a fine Investigation$of the DIA for insurance coverage verifi tiom !do hair ctr<iJj'�uxder poles d Pentida of p Ikat the hiformadox prorided above is lrw and corrertt Daw 08'lcla1 act onih Do not wrke In Ift areas,to be completed by clop or town 047cial City or Town: PermitiLicense q Issuing Authority(circle one): i. Board of Health 2.Building Department 3.Cl I own Clerk 4. Electrical inspector b.Other p for S.Plumbing In Contact Person: Phone q: t i Client A#alf4 ConserVision Pre-Work Tester ate Post-Work Tester Date Ai PRE BLOWER DOOR I POST BLOWER DOOR CFM HEAT FUEL- OIL TURAL GAS 11 PROPANE E r DHW FUEL- OIL NATURAL G S' -PROPANE ELECTRIC COMBUSTION UNITS- �BOILERFURNACE WATER HEATER WOOD STOVE OTHER RECORD AMBIENT CO PRE POST LIVING AREAS KITCHEN CAZ 1 WORST CASE DEPRESSURIZATION TEST PRE POST RECORD BASELINE PRESSURE ,O Ir ALL EXHAUST EQUIPMENT ON AIR HANDLER AND EXHAUST EQUIP. AIR HANDLER ONLY ACTUAL WORST CASE NUMBER CAZ DEPRESSURIZATION LIMITS (,CIRCLE PROPER LIMIT VENTING CONDRION LfMIT(PASCALSI ORPHAN NATURAL DRAFT WATER HEATER -2 S NATURAL DRAFT BOILER OR FURNACE COMMONLY VENTED WITH WATER HEATER -3 NATURAL DRAFTSOILER OR FURNACE WITH VENT DAMPER COMMONLY VENTED WITH NATURAL HEATER S INDIVIDUAL NATURAL DRAFT BOILER.FURNACE OR INDIVIDUAL WATER HEATER MECHANICALLY ASSISTED BOILER OR FURNACE VENTED WITH WATER HEATER a MECHANICALLYASSISTED SOLER OR FURNACE ALONE .15 CHIMNEY TOP DRAFT INDUCERIDIRECT VENT APPLANCEI SEALED COMBUSTION .50 F r yJ"F'I� t..t •• .. ...:< f T ft OWNER AUTHORIZATION FORM er -ISE_1►Z ��ii Z�y► i ommr of property located at hereby authorize ConserVision Energy,to act on my behalf to obtain a buildiM pemdt to perfom work on my property. Cyr Sigrmi ) aJV Date TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION `Map o'%% Parcel too4 f9 I t Application Health Division Date Issued 9 -I Conservation Division Application Fee Planning Dept. Permit Fee .00 Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis le i Project Street Address Village Owner 6_ k Z Address -%` Telephone Permit Request _w [��►'T w�� Z P,� , c Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay 00 Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Y: Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's-Highway: 'Q Yes.,^❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other =� Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) `> W Number of Baths: Full: existing new Half: existing neW cn 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 Telephone-Number _,-kcA- '%V& - Address 3,k4 License # k 0 c NA-ft „- p. o c.13 Home Improvement Contractor# �3i 7-5 i Email Worker's Compensation # Lc�� G,'Sti5 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO ��.�+•�• b� 'T3o.ski+..s� �.q v� s`i'-�t SIGNATURE DATE L FOR OFFICIAL USE ONLY APPLICATION# ' DATE ISSUED ti MAP/PARCEL N0. f ADDRESS VILLAGE OWNER • r a. `i DATE OF INSPECTION: FOUNDATION FRAME INSULATION ' FIREPLACE ELECTRICAL: ROUGH FINAL '• PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING f' DATE CLOSED OUT ASSOCIATION PLAN NO. )i nrjq=*=I a I Ivc un rlt uuu%.crs anu I nr-l.CIS I IrIL:a 11--nuLuets. IMPORTANT:If the certificate holder Is an ADDITIONAL INSURED,the pollcylles)must be endorsed.it SUBROGATION IS WAIVED,subject to the Wins and conditions of the policy,certain policies may require an endorsement A statement on this Certificate does not confer rights to the eaAficate holder in lieu of such endorsements. PRODUCER CONTACT � NAME: CS&S/WORKCOMPONE PHONE FAX A/C,No,Ed):EMAIL AfC,roo PO BOX 946580 ADDRESS: Maitland,FL 32794-6680 INSURERS AFFORDING COVERAGE NAIC# 1-877-724-2669 INSURER A Continental Casualty Company 120443 INSURED INSURER B. CONSERVISION ENERGY INSURER C: INSURER O: 376 ROUTE 130 INSURER E: SWITE 9 INSURER F: SANDWICH,MA 02563 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. NOTWITHSTANDINGANY 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. odat �' UBR POLICY NUmar:R POLICY EFF POLICY EXP LIMITS LTA TYPE OF INSURANCE NSR MNIDD MMIDD A GENERAL LIABILITY Y 6011316336 03M 1115 03/11/16 �OCCURRENCE REND 1.000.000 COMIdERCIAL GENERAL LIABILITY PREMISES(Fa omaer m $ 300 000 CLAIMS-MADE a OCCUR MED EXP(Arty one perso) 1 000 PERSONAL a ADV INJURY $ 1 000 000 GENERAL AGGREGATE 5 2,000.000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COTfi'!OP A60 $ 2000000 POLICY JECT X LOC c. BINED SINGLE LIMIT A AUTOMOBILE LIABn nY 6011316336 03111115 03/11/16 (Ea eca'. $ 1,000,000 BODILY INJURY(Per person) $ ANY AUTO ALL OMMEO SCHEDULEDBODILY INJURY(Pev etddent) _ AUTOS AUTOS PROPERTY DAMAGE NON-OWNED (Pei accident) $ HIRED AUTOS X AUTOS $ A upteRELLA LIA8 X OCCUR 6011316352 03111111 13111111 EACH OCCURRENCE 2,000,000 EXCESS E AGGREGATE O00 OOO $ ED RETENTION s 10 000 AWORKERS OY!I.IABUT YIN 6011316349 03111115 03/11/16 X roRv uMITS ER ANY PR�R:TOR/PARTNERlEXECUTR/E I E.L.EACH ACCIDENT $ 500 000 OFFICERN hMR EXCLUDED? NIA PManAetmy In { E.L.DISEASE-EA EMPLOYEE $ 500 0OO II yea.dear%ibe trader EL.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS belowOTK OTHER TORY LIMITS ER E.L EACH ACCIDENT $ E.L.DISEASE-EA EMPLOYEE $ El.DISEASE PPOuCY LIMIT $ 1;fYT1 tAt�cR'ACO/tl-1 IttCtrABTR�r�'S>:IrabU�tfTnOl6apHCe'IS'rea�11H�-- — — -- Certificate Holder Is added as an additional insured as provided in the blanket additional insured endorsement as it pertains to work being performed by named insured under written contract: INCLUDES PRIMARY AND NON-CONTRIBUTORY CERTIFICATE HOLDER ; CANCELLATION 1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Rlse Engineering ; THE EXPIRATION DATE THEREOF, NOTICE %MLL BE DELIVERED IN ACCORDANCE VMH THE POLICY PROVISIONS. 1341 Elmwood Ave Cranston,R102910 AUtHDRV.ED1 a•` ®t 988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(20101051 The ACORD name and Logo are registersd marks of ACORD i �• �� The Commonwealth of Massachuseds v Department of Indus&W Accidents ` O,f, 4ce of Investigadons 600 Washington Street Boston,MA 02111 www.mas&gov/data Workers' Compensation Insurance AlMdavit: Builders/Contractors/Electrictans/Plumbers Aonlicant Information Please Print LeQibl_v Name(B,nineworwizaponilr vide; ConserVision Energy Inc Address: 378 Route 130 Ci /StatelZi SAndwich, MA 02563 Phone#: 508-833-8384 Are you an employer?Check the appropriate box: 1.0 I am a employer with 6 4. ❑ 1 am a general contractor and I Type of project(required).- employees(fall and/or part-time).+ have hired the sub-contractors b• ❑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 S. 0 Demolition working for me in any capacity. employees and have workers' [No workers'comp. insurance comp. insurance.! 9. 0 Building addition regtriretij 5. 0 We ant a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their Plumbin g repairs or additions myself. [No workers,comp. right of exemption per MGL l 1.0 m12. Roof D insurance required.]t c. 152,110),and we have no repay 3a. Iama c tractor(a�g s a employees.[No workers, 13.©Other Weatherization comp.insurance required.] *Any WHem dm checirs box MI mint also tilt oa the section below showing theft woriteas'oo cy infotmsaas t Homwwnats who submit this affidavit indicating they are doing an work and they him outside Coatnrctots must submit a now affidavit indicating such tCouttwtora that check this box must attached as additional shoe!shownts the clams of the employwa, if the s tnscton have �and sate whether or tact those attida have etnplayeea,they mna provide their wottets'comp.policy a mbe, am an yrr that/s p vvldbrg workers'conrinjbrmadompsnsafiion Insarance for my employeeL Below is the policy and Job efts Insurance Company Name: CSBS/WORKCOMPONE Policy#or Self-its. Lic.# 6011316349 Cpiration pate; 3-11-2016 Job Site Address: City/Statemp: Attach a copy of the workers'compensation policy declaration page(showingthe Failure bo secure covers as llm�y number and expiration date) coverage required under Section 25A of MGL c. 152 can lead to the imposition of crimi�!penalties of a tine vP 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 violatcw. Be advised that a copy of this statement my be forwarded to the Office of Investigations of the DIA for insurance coverage verification. !do h00Y cep*under the pabtu and penahtes of perJary thw the lrybs�naNaa prerw-d above is&M and corms Dave Phone F(Ohther e only. Do Rot wrhr to Ift area,to be eompleaad by city or town o,0gcitrL wn: Permit/Ucense# thority(circle one): Health 2. $011411ng Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector rson: Phone#: OWNER AUTHORIZATION FORM t, on i Mc,rr wrd owner of property located at II Pe+er bosso/l Lri ems, &rns4G t , 00?66? hereby authorize ConserNision Energy,to act on my behalf to obtain a building permit to perform work on my property. Owner Signetare Date 31 dui Lt5 �oFrftrr�y Town of Barnstable *Permit# ti � Regulatory Services li.rpires nm h• iss� rinre Fe ^` BARVSIABL E, y 0A S. Thomas F. Geiler, Director U Building Division Tom Perry, CBO, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Fax: 508-790-6230 Not Valid rPithoul Red X-Press Imprinl Map/parcel Number 6v 1 V 1 Property Address 4�p=/ 0 ,lj{� ' v Darn. 4ah/, residential �—�(J Value of Work 6 Minimum fee of S35.00 for work under S6000.00 Owner's Name & Add►•ess -aHI �v Ma\--r ()a Contractor's Narne_ COO �„►y �O n/j"fauo4 e, ( o �3ti �Z Telephone Number J r ' Home Improvement Contractor License #(if applicable) / 5 �J Z Construction Supervisor's License#.(ifapplicable) /D D ❑Workman's Compensation Insurance Check one: X�PRESS PERMIT ❑ I am a sole proprietor 6'� ❑ I am the Homeowner OCT 1 5 2010 I have Worker's Compensation Insurance Insurance Company Name_ 47AS-)94—A TOWN Of BARNSTABLE Workman's Comp. Policy#_ f��6� ( ( 4/$ Aj y-7 ?Id Copy of Insurance Compliance Cert►ficatc must accompany each permit. Permit Request (check box) JOC Re-roofhurricane nailed) (strip ing old shingles) All construction debris will be taken to "'ItIf / l Q3� u r��l/e / ❑ Re-roof(hurricane nailed) (not stripping. Going over existing layers of rood ❑ Re-side ❑ #of doors Replacement Windows/doors/sliders. U-Valtte (maximum .35)# of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e. Historic.Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission, A copy of the Home Improvement Contractors License & Construction Supervisors License is required. SIGNATURE: 4-1Lb Q:1WPFILESIF0RMSlbuild mil Fo sl- PR S.do Revised 072110 r The Cainmoirwealilr of Afassachilsefts Department oflndustrial Accidents �t Office of lnwestigalioris 600 Washbi ton Street Bostort, 1'VLA 02111 farivw ninss.govldia 'Workers' Campensati.on Insurance Affida-vit: Bull ders/Con.tractorsJEl:ectlzciaus/PIumbers Applicant Tuform.atio:n / Please Print Legibly' Name (B•usine&vOOrrgmizatiou.'Individual): 02 le SCb�a'SyN/ - Address: J oo V9 n-w1 V t City/State/Zi:p: l .D -- Phone #: ru Z7 y�f �i you an employer?C eck tthe l proprinte box.: Type of project(required). 1.. I am a employer with 3 4. ❑ I am a general contractor and I ecuployees(full and/or part-time). * have hired the stub-contractors 6_ ❑New construction IR 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. employees and have workers' coo insurance..? 9. ❑.Building addition [No workers' comp.insatra�nce p' 10.❑Electrical repairs or�ddi:tians required.] 5. ❑ We.are.a corporation and its; 3.❑ .I am a.homeotivner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself [No workers'wrap. light of exemption per NMGL 12900ther Roof repairs insurance.required.]T c. 152, §1(4),and.we have no employees. [No workers' . comp.:insuria-m required.] •Any applicant that checks box#1.must also fill out the section below shawiug their workers'compensation policy information- 7 Homeowners who submit this.affidavit indicating they are doing sll wok and then hire outsidecontractars must submit.a uew affidavit indicating such_ rcamracinrs that checlt this:boat Mint attached an sdaional sheet showing the oame of the sub-contractors and state vrhether or not those entities-have employees. Tithe sub-contractors:have employees,they,must provide their workers'comp.policy number. I aunt an employer that is providing yr�or kers'contperrsattoN insuran.n9 for tt yv errrployees. Beloly is thepolicy ntr:d job site injorNi ation, insurance Company Nate: Policy#or Self-ins.Lc.#: Expiration Date: Jab Site Address: City/State/Zip: Attach a copy of the.Svo:rkers' compeirsation policy declaration page(s.h•o►ving the policy number and expiration date). Failure to secure coverage as required under Section 2.5A of MGL c.. 152 can lead to the imposition of criminal penalties of a fine up to SI.,500.00 and/or one-year imprisonment,as well.as civil penal.ii.es in the form of s 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 Once of Investigations of the.D.IA for insurance coverage veriffca:tion. I do herebv ce.rti the 'Is n atalhes of pevrj►rry that the hrjorrtta ran pros'ided above is true and correct Si lure: e� Dote: Phone#: Q(j cial use:ontlY. Do not write in this area,to bs coNipleted by citt or toivn o�cial City or Torn: Permit/License# IssuingA.uthority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4, Electrical Inspector 5. Plumbing Inspector 6, Other Contact Person: Plione M F (�.J�•0f THE 1p� lT - YT i s + flARNSTABLE, MASS. Town of Barnstable i6gq• 10 AIFD MAC h 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 .. . . .as O. .. ...wner o. .. f the subj_ ....ect_....--prop-------.erty.._...__._. ._ -....----_ .. --..._. .._.. ..-.. .._ _ . .. hereby.authorize // to act on my behalf, in all matters relative to work authorized by this building permit application for: e)Yn 4)1 , Ah 54,2� /e) (Address of Job) Signature of Owner Date a Print Name If Property Owner is applying for permit, please complete the Homeowners License Exemption Form on the reverse side. QAWPFILESIFORMSIbuilding permit forms\EXPRESS.doc Revised 07211 p 'Town of Barnstable ' 0, Regulatory Services its?ABLE, Thomas F. Geiler, .� rass. $ , Director .639. Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 548-862-4038 Fax: 508-790-6230 ------------------__________—_ HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: inumber street village I "HOMEOWNER" name home phone H work phone N CURRENT MAILNG 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 , 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 Homeo%rn.er Approval of Building Official t<.� 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 IS EXEMPTION The Code stales that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.) Licensing ofconstruction 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 oRen results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannotproceed 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 caret amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 072110 I, i c t i a f i Orrce o et r r tyg(,ta 1 Nlo,sacbu�etts - Deportment of Public S tt�t� HOME IMPROVEMENT CONTRACTOR- ��• $oard ()f Building Re�-ulations and Stan,(1:t;��Is r Registration: 159825 T e: a+ Construction Supervisot Specialty License YP ' Expiration: 5/29/2012 Individual License: CS SL 101023 'CO ^,estricted to: RF,WS - DALE COOKSON DALE COOKSON 55 BAYFARM DRIVE �: 55 BAY FARM DR VE PLYMOUTH, MA 02360 I PLYMOUTH, MA 02360% i Undersecretary r Expiration: 5/13,;9-012 ' ( nuni..inu•r Tr#: 101023 74 r .z Massite i`usEtts- Department of Public Safety '�Licen'se or registration valid.for mdrvidul use only Board of Building Re-gulations .did,•St trlda4'tis tonstrtTction S'u ervisot`.S ecialt License :• before"the expiration date If.:found return to:, �,, p P — Office of Consumer Affairs and Business Regulation : '� sLicense .CS SL 101023 a , " Y10 Park Plaza-Suite 5170 "Rest cted to RE WSWIM 02116Q DALE COKSON ,F h r; 55.6AY FARMDR y ::PLYMOUTH;MA 62360 }�1Vot:val�d without signature. r ;i - � '-�y . . Expiration: 5/1 0.1: ,. S. i t M. C7inuni�Sio�itu` Tr#: 101023 t s i ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) B 27 2010 PRODUCER Phone: 508-651-7700 Fax: 508-653-8089 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Eastern Insurance Group LLC - Commercial ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 233 West Central Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Natick MA 01760 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA:Hartford Underwriters Ins 301.04 Dale Cookson --- - --- - --- - - 55 Bay Farm Drive INsuRERB:Scottadale insurance Company Plymouth MA 02360 INSURERC: — INSURER D: � INSURER E: COVERAGES j 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 -1-0 WHICI.I THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HE:RRIN IS SUBJECT TO ALI, •1'I1E TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD" POLICY NUMBER POLICYEFFECTIVE POLICYEXPIRATION LIMITS LTR DD Y DATE B GENERAL LIABILITY CPS1032632 10/21/2009 10/21/2010 EACHOCCURRENCE _ $1, 000,,000,. _.. DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurence _$10 0.,000 Q _ CLAIMS MADE FO OCCUR MED EXP(Any one person) _ $.5,.000 PERSONAL B ADV INJURY $1�-Q 0.0 0 0 0_-_ GENERAL AGGREGATE_ $2, 000,.000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG -$2�-0 0 Q,�.0 0 0 }{ POLICY PEC RO- LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNEDAUTOS BODILY INJURY SCHEOULEDAUTOS (Per person) $ HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY..EAACCIDENT $ ANY AUTO OTHER THAN EAACC $ AUTO ONLY, qGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE I I AGGREGATE Is $ DEDUCTIBLE `$ RETENTION $ I $ WC STATU- OTH- A WORKERS COMPENSATION AND 6S60UB0148N27810 2/17/2010 2/17/2011 X._ TORYLIMIT$. ER, EMPLOYERS'LIABILITY E.L.EACHACCIDENT $5,00, 000 ANY PROPRIETOR/PARTNER/EXECUTIVE -.. - ---•— --------- - - OFFICER/MEMBER EXCLUDED? _E.L.DISEASE-EA EMPLOYEE_ $5 0 0.,, 0 Q 0 Ifyes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT I$5 0 0 0 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS orkers,Compensation certificate will follow from the carrier. he Workers Compensation policy does not provide coverage for Dale Cookson CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER INFORMATION PURPOSES ONLY WILL ENDEAVOR TO MAIL 1.0 DAYS WRITTEN NOTICE TO THE . . . CERTIFICATE HOLDER NAMED 'TO THE /.,EFT, BUT FAILURE TO DO SO . . SHALL IMPOSE NO OBL[GATTON OR I,IABIIATY OF' ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE / ACORD 25(2001/08) OACORD CORPORATION 1988 ~ TOWN OF BARNSTABLE t CERTIFICATE OF OCCUPANCY PARCEL ID 088 007 011 GEOBASE ID ADDRESS 11 PETER BLOSSOM LN PHONE (617)397-6938 WEST BARNSTABLE, MA o26hs ZIP 02668— LOT BLOCK LOT SIZE DBA DEVELOPMENT DISTRICT PERMIT 15077 DESCRIPTION BLD PMT 09552 PERMIT TYPE BC00 TITLE CERTIFICATE OF OCCUPANCY CONTRACTORS: Department of Health, Safety ARCHITECTS: and Environmental Services i TOTAL FEES: �TNE BOND $_00 CONSTRUCTION COSTS $.00 756 CERTIFICATE OF OCCUPANCY HARN3I,ABI.E, MAS& OWNER RUGGIERO, AGOSTINO & JANE 039. ADDRESS 45—A BRENTWOOD STREET MALDEN, MA BUILD G DI L. -.O. BY ' DATE ISSUED 05/10/1996 EXPIRATION DATE ' , ur ".j � u• 1. - .-. ...). •. ...♦1.1.:.�5:' ti,., •. .,. 1. x•..ill. r...... ..•.t. ... ... 1 l.•. r.1• l.. •...ri1... . OAR EL ID 000 (100 01U OBASE T]} ADDRE:'S 11 ''CATER BLOIC-11-DICMI. LN PHONE, {fi].7aj.:19'7 WL�:.;'I' BA) i�;:'T BLE, MA ZIP 02668-. DE "KL0P�11 1';' Di5?`RI(;T `iI IF 55'? DFSCRIPTIO N WNISVPRUCT SINGLE ill )'AAMMI ICY DWELL 1: �ti y tEiz�9I 7 T�s'P E EUILD TITLE: t� :��w ;:tE:,.-+�U BLDCO iiie nt o Health, Safety 1:�;�;•I�'r�,,(.��OE��;: r�>�(,z�;,'j,,� r){,��,, ,;�� and Environmental Services $133 .00 t.,)q,t . {��, rr'ur"Ti car: (�: S'I'S 3;3 00;+_)00 .00 �► i 011 ;-I ING,JE FAA TOME DETACHET. _. PRI.`JA'i':: P w. BARNSTA6LE. *' MASS. 1 `��► �bJi L� iiCi+1G....EI?U. 'kC '.l.'INO ri; JAPIE .1 DT'fll;i��"� 4,:%.-� R'}�{.L.f':11:e,o,j','t B`U,I/L _G DIVJSION h!Ult 1 , t' :r c t LATE B / THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET,ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR PERMANENTLY.EN- CROACHMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED BY THE JURISDICTION.STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS.THE ISSUANCE OFTHIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF FOUR CALL INSPECTIONS REQUIRED FOR ALL CONSTRUCTION WORK: APPROVED PLANS MUST BE RETAINED ON JOB AND WHERE APPLICABLE, SEPARATE 1.FOUNDATIONS OR FOOTINGS THIS CARD KEPT POSTED UNTIL FINAL INSPECTION PERMITS ARE REQUIRED FOR 2. PRIOR TO COVERING STRUCTURAL MEMBERS HAS BEEN MADE.WHERE A CERTIFICATE OF OCCU- (READY TO LATH). PANCY IS REQUIRED,SUCH BUILDING SHALL NOT BE ELECTRICAL,PLUMBING AND MECH- 3.INSULATION. OCCUPIED UNTIL FINAL INSPECTION HAS BEEN MADE. ANICAL INSTALLATIONS. 4.FINAL INSPECTION BEFORE OCCUPANCY. VISIBLEPOST THIS CARD SO IT IS BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 1 f fob ' 812,1019f 124J1 �� 1 Ly n L to' G 1 (,.c/eiy ua%ate a.9,o ctv Ff 2 2 2�c-,ate "s 1 H TING INS CTIO PP VAL ENGI RING DEPARTMENT 2 L BOARD OF HEALTH OTHER: Y• SITE PLA R VIEW APPROVAL WORK SHALL NOT PROCEED UNTIL PERMIT WILL BECOME NULL AND VOID IF CON- INSPECTIONS INDICATED ON THIS THE INSPECTOR HAS APPROVED THE STRUCTION WORK IS NOT STARTED WITHIN SIX CARD CAN BE ARRANGED FOR BY VARIOUS STAGES OF CONSTRUC- MONTHS OF DATE THE PERMIT IS ISSUED AS TELEPHONE OR WRITTEN NOTIFICA- TION. NOTED ABOVE. TION. 508-790-6227 To Date ZA Time 02 WHIL YOU WERE OUT M r of Phone l 7� ' 13?7—693 a Area Code Number Extension TELEPHONED PLEASE CALL CALLED TO SEE YOU WILL CALL AGAIN WANTS TO SEE YOU URGENT RETURNED YOUR.CALL Meaea I Operator AMPAD 23-021.200SETS EFFICIENCY® 23-421-400SETS CARBONLESS Y TO TIM DTf I/ J M_ Yclr see you .zg OF � �e° pMWants to�~ PHONE l �5�7 Will tall 3�Fe Y 'p tPERATO 23-024-400 SETS 23-027-200.SETS �'C - i „� V ��- r � � ��� � � � �: ,, � °�� �� � li- �; � u�.: �� ��� � �l 1 TO TIME DATE .,.. ..z , IN blWW'g� �� u[]�URGENT! �Q lelep M � Reiumed Qf lledto ' f � �� �tott see�y OF �Q Please �Q Wanis to PHONE QWitlw�ll [�Yae91 a'oin "know MESSAGE U OPERATOR: 23-024--400 SETS 23-027-200 SETS .. ... r ww.,..,,.. .... -. - ...-..,- "J t 1'n. ....,•,""�.,•..,..?.ab..'v:�- ! ,,1:i..v?y.,:+-..� :.*.., ti l r. •i .. i-Jr•, -...,_y.J!TT^...r• -'414.nq.p•a.s- v `�F1HE ip� The Town of Barnstable MRMA ABLE. Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis,MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner Inspection Correction Notice Type of Inspection Location 2d V� Permit Number _� 5 Owner Builder One notice to remain on jobsite, one notice on file in Building Department. The following items need correcting: Please call: 508-790-6227 for reeiinspection. Inspected by Date i o i i 1 -• --f,.i.}+,r:..'+.wl't..r�-, he,r-�% . ... - - -- - ,. ... .. .. e -*•+c:. "r,�. :ti;�. R•�-_. - 'r--.. -,,S'=.jt:~^^iFy.,.-�..^t'.f�S—.'C.�..1`.'a„�+,��� The Town of Barnstable ARM Department of Health Safety and Environmental Services 039. P Y o Building Division 367 Main Street,Hyannis,MA 02601 . Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner Inspection Correction Notice Type of Inspection 7�` VA- V Location } , ��L � ��lb�SQ�ut Permit Number C) 5 Z Owner Builder One notice to remain on jobsite, one notice on file in Building Department. The following items need correcting: (� 5�.1 Sc )LAST 1 c)(4 0 Ni N((3T Two -y5ulv C7 �-6 SW tn 61) Please call: 5088-790-6227 for reeinspection. Inspected by 1-{, S (a\( S Date Cow-0e0-o/9) '7�m p. .-._..-- a-7 .gam r sor's Office(1st floor) Map - t �'�; Lot Permit# \715aZ i Conservation Office(4th floor) Date Issued Board of Health(3rd floor)(8:30-9:30/1:00-2:00) 9� (O 7 i�Dee /3 3 • bZ3 Engineering Dept. (3rd floor) House#1 ,,-'Planning Dept. (1st floor/School Admin. Bldg.) _ �����+SYS �j/9 O A, 5 ,'teal PW oRt� �/� GM D niti an Approved by Planning Board �'" u19 E TLV, ,',��'k TAB. CODE AND TOWN Off'°BARNST) Building Permit.Application ---Pro reet Address // 2 , B105S"o m Ar fa _21R Al %a _. /Village `7-1 " Y— OSs 0,-7 - e Owner s N® V°' A Me V d Address ,,Telephone /7^ `�7^�0��� .f /Permit Request �L Total 1 Story Area(include 1 story garages&decks) square feet Total 2 Story Area(total of 1st&2nd stories) square feet Estimated Project Cost $ /D-D lJ-zjz) Zoning District Flood Plain Water Protection Lot Size Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use Proposed Use Construction Type Commercial Residential x Dwelling Type: Single Family Two Family Multi-Family Age of Existing Structure_`7,cAe_e_J Basement Type: Finished Historic House Unfinished Old King's Highway Number of Baths No.of Bedrooms Ja Total Room Count(not including baths) '�7� First Floor Heat Type and Fuel lNcee A r L?Jig Central Air Fireplaces / G�3 Garage: Detached. Other Detached Structures: Pool Attached ✓ Barn None Sheds Other Builder Information Name Telephone Number Address License# I 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 CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE 7/3 7 � BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S) FOR OFFICIAL USE ONLY PERMIT NO. 9552 DATEISSUED Aug. 7. 1995 MAP PARCEL NO. 000.000.019 (temporary ADDRESS 11 Peter 'Blossom Ln. VILLAGE West Barnstable, MA 02668 OWNER Agostino & Jane Ruggiero DATE OF INSPECTION: FOUNDATION jJ 34 FRAME �� a INSULATION - �' �iw61� FIREPLACE ELECTRICAL: ROUGH FINAL h PLUMBING: :ROUGH FINAL GAS: :ROUGH FINAL FINALBUILDING r DATE CLOSED OUTY u ASSOCIATION PLAN NO. 11.102/94 IT:02 $8177277122 1 C01junollulpaR ol Mamacliudeffi ... .1�aPrufixsel o�.,4iu�uefria�✓Acci�� James.J.i;ampbeii &I. , V"ud.,u fe 02f f 1 Commissioner Work ' Compensation lnsurance Affidavit caom:adpam�► 4-7 with a principal place of businim ac c�rsrm►zl� �� . do hereby certify under the pains and penalties of perjury, that: () I am an employer provid'mg workers' compensation coverage for my employees work! this job. Insurance Company Policy Humber () I am a sole proprietor and have no one worsting for me in any capacity. I am a sole proprietor, general contracxo or hom (drde one) and have hired contractors ilsced below who have the fog workers' c ensadon polder. Insurance Companyfpolicy Nui Contractor Contractor Insurance Company/Policy Nur. v !Policy Nur. Contractor Laurance Company () I am a homeowner performing ail the work myself. I undecsnnd:.,u a cot:f of this s:a&= nt wiU be fo.-carded to the OMM of ImvesdSadons of the CIA for oovecage verffk:2Van and that hHur cme.ie zs r cuired under Sect On ZSA of MGL i S2 can lead to the Wvwkhm of aunnal pautldss CxVWQe of a not of up to S 1,500•0( years' irn;dsc-mn m as well as civil penaides in the(om:Of a STOP WORK ORDER ind a fine of S100.00 a day aOnst mc- igned this k day of 'censeelPermittee Building Department Ltceasing Board Selectmen Office Health Department �o � Application to � eA p 1 ,25 Old Kings Highway Regional Historic District Committee - in the Town of Barnstable for a 9 ,► , CERTS FIC!! ' :�F a PP ®PRIATE ESS "~ ,liV'Ii''1.b1 jr+! ,;•� arl r .s: „ s 1 ... s Application is hereby made,.iri triplicate, for the issl�ani a of wcertificate of Appropr1atenass'tio&r Section 6 of Chapter�470, Acts and Resolves; of Massachusetts, 1973, for proposed work as described below and can,plans, �elrawings or,photographsaccompanying.thisiapplication for:-) r CHECK CATEGORIES THAT APPLY: 1. Exterior Building Construction: New Building ❑ Addition ,El-.Alteration ; lndicate'type of Building: Mouse Garay ' " ❑ j C3ther . :_„ J7 2. Exterior,Painting:a z,i< `«►; , ,a Commercial 3. Signs or Billboards ® New sign f A ❑ Existing sign ' s, ❑`,Repainting existing sign , r it, #., 4. Struc%urer- ['Fence [] Wall Flagpole ❑ Qther � ' 1r- ' (Please read other side for ex'Planation andre uirements): TYPE OR PRINT LEGIBLY, _ -7 t; DATE '` G�1' 1�/ ADDRESS OF PROPOSED WORK !d/ ° C�/1 /l%S'T L L^�' ASSESSORS MAP NO.�[. OWNER &0 ND ����� /C��'T°` `l'U _ ASSESSORS LOT NO. HOME ADDRESS /7 ' n .` � � ���7/ oa 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). 63a AGENT OR CONTRACTOR TEL. N0. . �yyy, , ADDRESS DETAILED DESCRIPTION OF PROPOSED WORK: Give all particulars of work to be done(see No.B,other side),including materials to be used, if specifications do`not'acco'mpany plafis. Ir-the case of signs,' locafio'ns of existing signs`and proposed locations of new signs. (Attach additional sheet, if necessary). A D /v Q-G✓ �—/�� v�ig L' `7 2'� 'e�oo��drt •e. . nn .� €h:. r► .• ;+ , U ROVED Signed _ Owner-Contractor-Agent Space below line for Committee use. e �� I Y / D FDate e i to is here lv r Date UN 2 91995 NN OF BARNSTABLE S2LUr1=HlG1.1 Approved ❑ IMPORTANT: If Certificate is approved,approval is subject to the 10 day appeal period provided In the Act. Disapproved x Town of Barnstable ' ®Id King's Highway Historic District Commission !; u SPEC SHEET FOUNDATION —3(2x /O*X/ SIDING TYPE /lc,/�� %��p. COLOR CJt: / CHIMNEY TYPE C(.Qd2� COLOR�L�_ ROOF MATERIAL /-SST. `,a �/I/i�►c����' COLOR 5/2D �� PITCH wlNDow c1u-llF' yll �� SIzE TRIM COLOR GW/ -� DOORS ,SO_ �-�v� COLOR SHUTTERS GUTTERS �� //(�i� r -�- �vt �, l Pss lft�t m lf✓u - 'DECK � l ? /y //�Sr�1.e GARAGE DOORS /6 K7 ' Sq� /.L �o COLOR NOTES: Fill out completely, including measurements and materials/colons to be used. Three copies of this form aie required for submittal of an application, . along with three copies each of the plot plan, landscape plan and elevation plans, when applicable. Plot plan need not be "Certified"F but should show all structures on the lot to scale. d DDD 0 D SPECSHr I �k•:'` ' •sf "'",,`�...y rt •,y'+.i.,`s. .'711"_�4gfi.rsa.� �c••.x,,.^saN ;-,,..r•y�-v fez .`r- —77;:r.n-yh, rr,.r-1tiy'A: ik • , .. ' Z Ty , • 1 '-EB,T HOLE LQQS t -All J•0•b�S,L+ t9.4!_ <.5 m xcx4l es,-KA to ana P or iw.Ix1A{I[ MX;ESS.04R(WATE O M To ENGINEER:USwF1 •OV l=Fl,u w ap - rAnw IF OF n1I.GRADE ax SLOPE REMM NIr W.75'OF.�..• OWR PRFCASI / ID IN"STSRY_ _ - _ f 1+►.v, - rrw (I�* M �.� / WITNESS:�• r DOUOLE i _ RUN PwE tP¢ .`_•I,,_ \IRb•0 _ �'1 .w eo 1 II - loa5_) FOR rWrs r / WASHED Pctnat[aRstaa ro a/�ro f a►Z GATE:_ LI 11 P as�Eus II _.._ _ pn per! -.�._ -^v.,r,. I Sr �14285 PERC. RATE'�Lox t'R4.1 >7•MtwI1`�rt ••'1 �NSr{) "ado sr�- - or mac oon...A 6.IY3t1�14 o.6f 1 ISOG / y (1 x ��vm°�� eo.°?e - _ r° cuss sass P/ , L.x Sr) r eI 10 BONE OR NECwwleu \ « 2 143.00 '\' --• 3_S9CE_.!_'!v l_--- '9G 6 o ol�{. DEPTH OF FLOW _.-_ ..cOrP.[I�oN.(Is nl IaU - \-3/0'TO 1-//7 Oouat wvm STOW S .S rEE SIZM. s' L x SLOPE) Lx SLOPE) MM.•1 RJ.1 Tis. w V DEPTH-—1i ..,;lf+' aOEa AM 00nw OF lLbl WTEIIFAR To 0[swam 1 r N7,s LOCATION HAP Y - •X OUTLET"m ASSESSORS MAP 109 PARCEL F'OUNUA110N -17/ SEPTIC TANK S - "- -0' BOX-' - -- FACILITYC SA„0 F1000 ZONE .:� r , Ate BUILDING ZONE: -E._/'Ac¢E SETBACKS: FRONT - SIDE - i31_ 115.r REAR -I IS . (�A o..,T otaa-QvrD C��nsta.. PO% PLAN REFERENCE:Va�ty LOr 11 p SEPTIC DESIGN: (DA/m`cE 0r5POSOF 01 wlaT A'E-L°"'iieO i DESIGN FLOW:3 BEDROOMS 0110_ GPD) L CPO NOTES; r c o f�`�-�•- USE A'1'11 CPO DESIGN FLOW 'y SEPTIC TANK: W_ GPO (LO.) - t40 GALLONS 1. DATUM IS-hI_4A.1L— r so � rf aY - USE A{ GALLON SEPTIC TANK MIIJ 1,10•T s { 2. MUNICIPAL WATER 6 +11 \\ ` LEACHMy. `.1 3. MINIMUM PIPE PITCH TO BE 1/1'1' PER FOOT. SIDES: Y T Ioo•('GPO 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AkW-H1G_ 4 T BOT70 -�qL(g a Ito I CPO $. PIPE JOINTS 70 BE MADE WATERTIGHT. TOTAL- ;CG S.F.a<a� 1fl9.4 GPO K2=378.8 Qr�p 6. CONSTRUCTION DETAILS 70 BE IN ACCORDANCE WITH MASS. .; •h 1. ` §TZ•�OFTT1l-. NVIRDNMEMAI CODE TITLE V. � •+• i + 7, THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE NSSAQ3.._�t.K w - - USED FOR LOT LANE STAKING. I _ 'I 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. . �FJ \\ \\ L: 1 •' 9. �.a�.. a n::.N+:Ni wrr�io wA:.T a.pr,�v,rfrM '7 1 `. 10. COMPONENTS NOT TO BE BACKFIU_ED OR CONCEALED WITHOUT •� �� .I I \\� • INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED >�; •� FROM BOARD OF HEALTH. `? 11. IT IS THE RESPONSIBILITY OF THE OWNER OR THE OWNER'S ' AGSM TO CONTRACT WITH THE DESIGNER FOR INSPECTION AND .� A•oRM I ` I I ASPER CERTIFICATIONOF CONSTRUCTION AND LOCATION OF SYSTEM AS '1 PER TITLE S REGULATIONS. 1r 12. VEHICULAR TRAFFIC, PARKING OF VEHICLES. STOCKPILING RO OF MATERIALS ; I � AND STORAGE OF EQUIPMENT OVER LEACHING AREA PROHIBITED AT i• 1Av / / it / /f Z ' ALL TIMES. ��. y//J/• / o IA Ib �� / /V A". -•:� f� 13. SYSTEM AREA SHALL 8E STAKED AND PUGGED FROM DATE OF 1 11A Ty / Jr, J INSTALLATION UNTIL CERTIFICATE OF COMPLIANCE IS ISSUED. 14. AREA DOES NOT LIE WLTHIN NITROGEN SENSITIVE AREA. 1 •,Q 4 Oil //� / oi• 1St Na4r^A0.K ` �• 151�1Z4.90 SITE AND SEWAGE PLAN OF , ---�� 1 wAm or EUALte l•n'f Il._�lJp.R• yi---- T 't.• / J'- _s O / N/ _ _ IN THE TOWN OF. ..1 APPwvaD DA* C z� 1G (Ir1�y1� h►a.��iT�HL.E I,' ,T'�+`''•SF•�:L '� :%F'",� /r'r'�%/ - PREPARED FOR: Mg,WA". N. L.I/rblL�Pe ' BCAU: 1`=3c p i JU1JQ' \4v111s'— r !. L_t down cape engineering, inc. aeLA ARSE f� •y CIVIL ENGINEERS �• A SURVEYORS t ^�+ ! j I LAND s Pa L" • „xaa aaraar� Ru.r ORS �N ro �C��� .:•i JOB S( pls la� 999 main et. yarmouth.ma A oJAy�, .45. DATB ` :. // 1. ., ... J ti ¢y da".;:►S.! .�.. r;,,tiaxT r yy' I:rf-:„r:..�- -t./N`?.t E ,,.?. •rT'+.t.-I. T r:.•',a KfA L-- .✓J �j Fee--- - -t ------- K� BOARD04! o OF HEALTH 12��I m i'OWN OF BARNSTABLE 0(pp[icat ion AnVeil Congtruct ion Permit I I Application is hereby made for a /p r o C nstruct ( , Alters ), or Repair p4an individual Well at: ......... /—Z----�---A ,�- ---_ Location ' A - - `--•-/� �07 Assessors Map and Parcel Location — A ress Address caner -- :, _- `---------- �'�a -DR� r ^!s— �---------'-� - - �7 ...-..----•-•----•----•-- Address Installer — Driller a Type of Building ✓ Dwelling - Type of Building-------------------------------- No. of Persons----------- --__--_—___ Type of Well Purpose of W ell-----`��--{-�-__�� -��� --�T�/�✓IPSs -.�ClW�apacity----------��—/S�I�'/it,�_---- : � — ---- Agreement: The undersigned agrees to install the aforedescribed individual well in accordance with the provisions of The Town of Barnstable Board of Health Private Well Protection Regulation — The undersigned further agrees not to place the well in operation until a Certificate .of Compliance has been issued by the Board of Health. Signed '— —' —-- date Application Approved By- — -— date Application Disapproved for the following reasons:---------- - - ------- --- _—' — --------- date -- Permit No. - A-5--�5 ---- Issued-- — - — — r date BOARD OF HEALTH TOWN OF BARNSTABLE Certificate Of Comptiance I THIS IS T CERTIFY, Tha the Individual Well Con tjucted6( ), Altered ( ), or Repaired ( ) Intaler �n/ A �_M Ihas been installed in accordance with the provisio s of the Town of Barnstable Boa d of Health private Well Protection Regulation as described in the application for Well Construction Permit No._�`--_S, ated---------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE WELL SYSTEM WILL FUNCTION SATISFACTORY, DATE --- ---—--- --- - — Inspector— - - —— ---- --- -- ----- BOARD OF HEALTH TOWN OF BARNSTABLE ,,, Merl Con$truct ion Permit a ' �.x.r W.Lwrl. � � MOp1 lar AIPxALT Sx+SU. - - _ _ i�l ier Y "1'. 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''�� • TOWN OF BARNSTABLE • BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Please print. ./ DATE /JOB LOCATION 31Oss p/� Lf Number Street address Section of -town "HOMEOWNER" p s'/�OZaa1j2'f'd _ l. .... ..... w ame Home phone Work phone PRESENT MAILING ADDRESS__-�� �P151V 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 such homeowners to engage an in- dividual for hire who does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER: Persons) who owns a parcel of land on which he/she resides or intends to re- side, on which there is, or is intended to be, a one to six 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 Stat Building Code -and other applicable codes, by-laws, 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 co ly with said proced es and requirements. HOMEOWNER'S SIGNATURE ` APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings 35,000 cubic feet, or larger, will be required to comply with State Building Code Section 127. 0, Construction Control. 3 HOME OWNER'S EXEMPTION . The code state that: "Any Home Owner performing work for which a butlding permit is required shall be exempt from the provisions of this section (Section 109. 1. 1 - Licensing of Construction Supervisors) ; provided that,:if Home Owner engages a person(s) for hire to do such work, that such Home Owner shall act as supervisor. " Many Home Owners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q, Rules and Regulations for . licensing Construction Supervisors, Section 2. 15) . This lack of awarenes often results in serious problems, particularly when the Home Owner hires unlicensed persons. In this case our Board cannot proceed against the inlicensed personas it would with licensed. Supervisor. The Home "Owner-' actin as supervisor is ultimately responsible. To ensure that the Home Owner is fully aware of his/her. responsibilities,. man communities require, as part of the permit application, that the Home Owner 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 to amend and adopt such a form/certification for use in your community. I I y� s77 0, 99 LOT 11 LOT 12 43.632 s.f. �% 1.00 acres 0 0 o Ln -- p co rod` yy ti row B [u O�h0 O� o LOT 10 � row^. JOB # 95-189 CERTIFIED PLOT PLAN LOCATION : PETER BLOSSOM LANE REST BARNSTABLE, MA SCALE : 1" = 50' DATE : 8-11-95 PREPARED FOR: REFERENCE LOT 12 LCP 40599 A UGIE R UGGIERO I HEREBY CERTIFY THAT THE STRUCTURE SHOWN ON THIS PLAN IS LOCATED ON THE AM Of GROUND AS SHOWN HEREON. ' oe 508-362-4541 r� aoe:asz-pe6o OJMLA I I N down cape engineerz.V: inc. `, !S ;- ice CIVIL ENGINEERS -( LAND SURVEYORS C--F-------- --- ------- - ZpM� ese main st. Yarmouth, ma DATE REG. LAND SUR