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HomeMy WebLinkAbout0010 SCORTON HILL ROAD /D C.�o f�i�l1 �� ��-. �, �. -_- - ---- �-- _ . t ._. .u�-- � �� �� �`` i I 9 i �q�YT� ��e��� `9 ® � � �� I - , �® � �M vi (k � e-Ln c� (�Ar��/�� � � I [9!�� y I �� � S .I l �� TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION /.D &o Map \ 1 \ = Parcel 7i7� Application Health Division Date Issued 1 Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Q(G Historic - OKH _ Preservation / Hyannis �Q Project Street Address - 1 Village Owner Address Telephone Permit Request ' a Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District 6I�Flood Plain Groundwater Overlay Project Valuation o 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 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 Roo .Count ° 4 Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other k.;77 0 ZE e tl Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/c�O��al stove Ye9❑ No co Do Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing O.new�;pize_ =s: c+� Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: co —a V7 rh Zoning Board of Appeals Authorization ❑ .Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) r 'r Jame 10 )f Telephone Number f 50 Address w� License # MOAS Home Improvement Contractor# Worker's Compensation # 44 -711 a SQ k 1q" ()19 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO kh, . SIGNATURE - DATE u k FOR OFFICIAL USE ONLY a APPLICATION# DATE ISSUED s MAP/PARCEL NO. y ADDRESS VILLAGE OWNER - t 1 1 DATE OF INSPECTION: FOUNDATION _ FRAME - INSULATION FIREPLACE �f ELECTRICAL: ROUGH FINAL . PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING AL, } DATE CLOSED OUT, ASSOCIATION PLAN NO. 4 RISE E1VGII�TEER�IQi Federal ID#05-0405629 RI Contractor Registration No 8186 A division of Thielsch Engineering MA Contractor Registration No 120979 CT Contractor Registration No 620120 1341 Elmwood Avenue,Cranston,11102910 w' p �1t/i (401)784-3700 FAX(401j 784 3710 -n 2�(� :'I ®e�1CT ' '! !Page 1 R I S E -THIS CONTRACT IS ENTERED INTO BETWEEN RISE 'ENGINEERING AND THE CUSTOMER FOR WORK AS ENGINEERING ..__....__.......... ...::... ... DESCRIBEDBELOW CUSTOMER PHONE DATE Client# Clayton Conn (508)362-2905 10/04/2009 104604 SERVICE STREET BILLING STREET 10 Scorton-hill Road 10 Scorton-hill Rd SERVICE CITY,STATE,ZIP BILLING CITY,STATE,ZIP West Bamstable,MA 02668- W Bamstbl,MA 02668 JOB DESCRIPTION RISE Engineering will provide labor and materials to seal areas of your home against wasteful,excess air leakage. This work will be performed in concert with the use of special tools and diagnostic tests to assure that your home will be left with a healthful level of air exchange and indoor air quality.Materials to be used to seal your home can nclude caulks,foams,weatherstripping and other products. Primary areas for sealing include air leakage to attics,basements and other unheated areas(windows are not generally addressed.) This work will be performed at the rate of$66 per man per hour,which includes materials and testing. 8.5 man hours. $561.00 RISE Engineering will provide labor and materials to install a 7"layer of R-23 Class 1 Cellulose added to 1008 square feet of open attic space. $1,008.00 RISE Engineering will apply all applicable,eligible incentives to this contract. You will be billed only the Net amount. Currently,for eligible measures,the Cape Light Compact offers 75%incentive,not to exceed$2,000 per calander year. -$1,176.76 WE AGREE HEREBY TO FURNISH SERVICES-COMPLETE IN ACCORDANCE WITH ABOVE SPECIFICATIONS.FOR THE SUM OF ***Three Hundred Ninety-Two&241100 Dollars $392.24 UPON FINAL INSPECTION AND APPROVAL BY RISE ENGINEERING.CUSTOMER AGREES TO REMIT AMOUNT DUE IN FULL.INTEREST OF 1%WILL BE CHARGED MONTHLY ON ANY UNPAID BALANCE AFTER 30 DAYS.SEE REVERSE FOR IMPORTANT INFORMATION ON GUARANTEES,RIGHTS OF RECISION,SCHEDUUNG,AND CONTRACTOR REGISTRATION. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES { AUTHORiiE8 SIGNATURE-RIS ENGINEERING CUSTOMER ACCEPTANCE NOTE:THIS CONTRACT MAY BE WITHDRAWN BY US IF NOT EXECUTED WITHIN DATE OF ACCEPTANCE -3V ACCEPTANCE OF CONTRACT-THE ABOVE PRICES,SPECIFICATIONS AND CONDITIONS ARE SATISFACTORY TO US AND ARE HEREBY ACCEPTED.YOU ARE AUTHORIZED TO DO THE WORK DAYS. AS SPECIFIED.PAYMENT WILL BE MADE AS OUTLINED ABOVE / icensee Details Page 1 of 1 The Official Website of the Executive Office of Public Safety and Security(EOPS) Mass.Gov Home Public Safety Department of Public Safety Licensee Complaints License Type Construction Supervisor License# 100459 Restriction WS,IC Name Erik Nerstheimer City,State,Zip North Scituate, RI, 02857 Expiration Date 3/28/2012 Status Current No complaints found for this Licensee. Back To Search GTE.-P�u�u ✓G�� e� ' 'i:.;:; '<:.:;.:;=-:..� ._......,..: . Board of Building Regulations and Staiidaril License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR i. before the expiration date. If found return to: _j Registration:. 12097g Board of Building Regulations and Standards Ez iiaYion. I One Ashburton Place Rm 1301 P, : =3125/2010 ; T,..;, ;, '..nston,Ma.02108 .ype.:Supplement Card THIELSCH ENGINEER NGS•— ERIK NERSTHEIMER_'.2 1341 ELMWOOD.AE_` = CRANSTON, RI 02910 �'..,.. — -- -- ----__ ;. Administi::itor Not valid without signa:wfre ! http://db.state.ma.us/dps/liedetails.asp?txtSearchLN=CSL100459 o/,)n i1)nnn I CIX The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations UV 600 Washington Street Boston, AM 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): RISE Engineering; A Division of Thielsch Engineering Address: 1341 Elmwood Avenue City/State/Zip: Cranston, RI 02910 Phone#: 401-784-3700 or 1-800-422-5365 Are you an employer?Check the appropriate box: Type of project(required): 1.❑X I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.© Other comp. insurance required.] *Any applicant that checks box tll 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: The Preston Agency Policy#or Self-ins. Lic. #: 1,�`!—l� 1��� lq Expiration Date: 04/01/ 10 _ Job Site Address: l Mffi1 lit I kd City/State/Zip: JT�J� �d'tY�lj 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 1250.01 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 un r the ins an penalties of perjury that the information provided above is true and correct Signature: Date: Erik Nerstheimer for RISE Engineering Phone#: 401-784-3700 or 1-800-422-5365 Ext. 133 Official use only. Do not write in this area,to be completed by city or town official I 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#: ACORD THIEL-1 1 05 CERTIFICATE ®F LIABILITY INSURANCE OP ID DATE1/05/Yv 9 09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIO The Preston Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 1350 Division Rd Suite 303 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR PO Box 810 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW East Greenwich RI 02818-0810 Phone: 401-886-8000 Fax:401-885-1700 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Hartford Underwriters ins. Co Thielsch Engineering, Inc INSURER B: Hartford Casualty insurance Co Hi Tech Group Inc. INSURER C: Liberty mutual insurance Group Hi Tech Realty Inc. y P 195 Frances Avenue INSURERD: North American Capacity Cranston RI 02910 INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. POLICYEXPIRA LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MM/DD VE DATEIMWDDfMN LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY 02UUNTD5678 04/01/09 04/01/10 PREMISES Eaoccurence $300,000 CLAIMS MADE �OCCUR MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,0 0 0,0 0 0 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,0 0 0,0 0 0 POLICY X JECOT LOC Emp Ben. 11000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 11000,000 B X ANY AUTO 02UENTD4850 04/01/09 04/01/10 (Ea accident) ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NO OWNED AUTOS (Per accident) $ N PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ 10,000,000 B X I OCCUR F ]CLAIMSMADE 02XHLTUF6573 04/01/09 04/01/10 AGGREGATE $ 10,000,000 $ HDEDUCTIBLE $ X RETENTION $10,0 0 0 $ WORKERS COMPENSATION AND X ITONYTIM17 ER_ C EMPLOYERS'LIABILITY WC2-Zll-259874-019 04/01/09 04/01/10 E.L.EACH ACCIDENT $ 500 000 ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? E.L.DISEASE-EA EMPLOYE $ 5 0 0,0 0 0 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT 1$ 5 0 0,0 0 0 OTHER D Professional Liab DVL000025902 04/13/09 04/01/10 Prof Liab 2,000,000 A Leased/Rented Eqp 02UUNTD5678 04/01/09 04/01/10 Equipment 100,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION TOWN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN Town of Barnstable NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Building Division IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR 200 Main Street Hyannis MA 02601 REPRESENTATIVES. AUTHORIZED ftEPRES ACORD 25(2001/08) ©ACORD CORPORATION 1 •>#�-y a'EASY�1 trm rq-Zo rs 1-t'71 3 c, C-n p '�d�Z1 cy ray h► t.,3 �uly,-"' 14,Z-ja I n [�aa -:ins/ft--->N tZ t4<g s V w g %V-Lt; t Ci 14 tv t o rv,-n ca_L- - -7-7 Ef 01 S!u-24Oat ry a D ` l 3 f ,-7 1 ..L `t r^ r r I r .� n o _lzi 21-ro 1 Z-=)• I L =-I LP Z7 i r r � � f `1 F 1 o } • y ^'" r•' T. �•l' wit r . '- . ,• - TOWN OF BARNSTABLE Permit No. Building Inspector cash _ mu �'°..�► OCCUPANCY PERMIT Bond No building nor structure shall be `erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to S. Alan Becker Address r) --Jr Sixtiet/10 Sco ton i,:'_1 Rca . Wiring Inspector - fir., Inspection date ! y Plumbing Inspector,(- fl_ ' Inspection date Gas Inspector Inspection date !Engineering Department r' / Inspection date/ THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. __. ._.. ......... , 19 ...................... .......Building�Inspeetor Assessor's map and lot number .. . .................. �. C J Bpi THE r Sewage Permit number ........ ...................................... P �„ / LE, House number ..............�0 r.................................... r � E 9 �p t639. \0� ENVIRONMENTAL COD a TOWN OF BAIRNSTAc LEGULATIONS BUILDING IKSPECTOR Q APPLICATION FOR PERMIT TO CD.�Isr,�UC> X-4 S'r,Pi6AIC4 ............................................................................................................................. TYPE OF CONSTRUCTION ��� �� .....-IUlVE . ZFL 19.7.7 ............. .:.. ........ TO THE `INSPECTOR OF BUILDINGS: M111AI � T The undersigned hereby applies for a permit according to the following information: Location ....................................................................................................................................................................................... Proposed Use .......'ES%U�i1/G� ............................................................................................................................................................ Zoning District 'le .............................Fire District -.............................................................................. `��NST����' .�. Al-,4 N %� c���' ......Ad 78'0 8D�1L�T4�/ ST. 7�osroN,�lq, a21 y� Nameof Owner ................................................................ dress .................................................................................... Nameof Builder ....................................................................Address .................................................................................... ��S/G✓pe �/�,P�...!!�iQE�I Address Nameof Architect ........ ......... ............... .................................................................................... Number of Rooms Foundation Exierior ! ...............................Roofing .. Fi.Yir. r-o Eelaoo Q,v 51g, Floors .....�.....Interior ....0/2 `/�a/�LL �.pi9fY�lG/r✓� ........................................................................ . ........................................................................ Heating .'�l ECTG ...............................Plumbing .C�J�P'L`'�.....��1/G.......................................... Fireplace 92ecle.............................................................Approximate Cost ` 5-5 avw- ............ .................................... .... /�9 ...s� .:..... Definitive Plan Approved by Planning Board -----------_______------------19________. Area ............... . .. . Diagram of Lot and Building with Dimensions Fee // SUBJECT TO APPROVAL OF BOARD OF HEALTH �1 l G � I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable r gard' g the above construction. �� �L�cLcc�� �� Name ..... ....... ...rr.............. BeckeA, S. A2an A=111-22 sewage #79-358 jo 4$46...... Permit for ....11.,,btoky..d oe,?,(ing .................................... P Location5�....Q ....,��,/.. �Q4 G/,, .......................................... owner ..S...AZa&.Reeke&................................. Type of Construction .........Aam...................... ............................................................................... Plot ............................ Lot ................................ Permit Granted ..............Augu4t.....1-0....19 79 Date of Inspection ......."....... ....................19 • Date Completed ...19 /.. . ?,�..rr�............ z/g� L PERMIT REFUSED j .. .fpg. ......... %..�. . .'T. ........ 19 CA4- ....... !. . ............................................ .......................................... ^ . Appr M S ... 19 .......... . ;. ................................................. ............................................................................ p ���....'.�.... ..... *T Assessors ma and lot number Q!/�C/i%!- C!�r /1 Qy�f THE Sewage Permit number ......:... .. ....................................... • . 33AHB9T/IDLs House number .............. CO........................._....................: *oo •� MAB& i639 \e 0 NAY A" � . TOWN 'OF BARN.STABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ..................................✓c '..�5%��Eit/C�............................................... TYPE OF CONSTRUCTION ...GUDO.O...........i�� ...................................................................... ...................✓U/VE.......2!..19. TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location ... ...vTE �/4 .¢/✓p SCO�TDi✓ /�iLL /�jS —GUEST" 3�q.e../ST/lBGG y DES/49•--A1C.E , ProposedUse ............................................................................................................................................................................. y Zoning District .........41.a.......................................................Fire District -5..........: ..•2�/ST ALE 3.............. ....................................... Name of Owner S- ALA /V �r C/��.2 7�G cF4)Y/-5TDA/ Si. 6DSTON,�I.q, �Z l57 9 v, .....................................................................Address .................................................................................... Nameof Builder ....................................................................Address .................................................................................... Name of Architect ........ 'P'e� �.PE BL F Address �3'��... �1lPS kk! -X;e A0 aFV/25:*X e�GE ....... ................................................................ • Pau �.v Number of Rooms .......Foundation ........................e2cTE . ..............................................Roofing Exterior ... ............................ ........ Floors TiNiJ.ye'D lf/da0 dt� s�8 SdBfLOer.. Interior ....�J/?//rJ�LL . ..................................................................... ........................................................... Heating EL.ECT2lG --- - ....Plumbing ...........................................` / G .........:............................. .. zFireplace ....��e C&.............................................................Approximate Cost �' a.o..-a...v................................................... ..:.......... . . Definitive Plan Approved by Planning Board -----------_______-----------19_______. Area .... `I. : Diagram of Lot and Building with Dimensions Fee ..........?.+.....1. . SUBJECT TO APPROVAL OF BOARD OF HEALTH oo- k"I I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. ; CG� v -� •(� Name .....``�....... .......... ... .................... Becker S. At - an .6 ewag 6#7�3- No 21546....... Permit for .....1 '--4t44Y--&te,Q,Pavtg b........................... : .................... Location ...... ... '�"'C. .... w Hi e�5 $cll4Yl1,? fa ................ Owner ...S.e...gaa-Be zt........:....................... Type of Construction .....4-ww.......................... . � Plot ....................... Lo.. Lo ................................ Permit Granted ........... .....Aug zt..••1.0.19 79 Date of Inspection ... ................................19 Date Completed ......................................19 PERMIT REFUSED ................... ....................................... 19 .................................................. �� - �. A......... ......................... Approved ................................................ 19 ............................................................................... e ............................................................................... I l TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Permit# (Health Division qfl �eqZA /VvD6 Date Issued Conservation Division Fee XTax collected a .Treasurer. - I U INSTA LLB)E,+) (,,�N d LIANCE eu litl8 .�� Planning Dept. ENVIRON ,B � a': r�a r o i a�� L COME;AND Date Definitive Plan Approved by Planning Board ►�,�.L"'r" 3NS Historic-OKH Preservation/Hyannis Project Street Address O n l Village 4 /dl /' A/S/•� Owner !i' 4/S/ ^!��-`` Address ,Z2 Telephone Permit Request Square feet: 1st floor: existing proposed 2nd floor: existing proposed Total new Estimated Project Cost Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Fam :Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No Basement Ty'pe,b Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing 1> new Half:existing new Number of Bedrooms: existing 3 new Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil Electric ❑Other Central Ai��Yes ❑No Fireplaces: Existing —A 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: �r Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes,site plan review# Current Use Proposed Use BUILDER INFORMATION Name Telephone Number Address License# . Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE �. FOR OFFICIAL USE ONLY f <3 1,Tt Z_ • PERMIT NO. r DATE ISSUED MAP/PARCEL NO. ADDRESS , VILLAGE OWNER ' + DATE OF INSPECTIO c FOUNDATION ` FRAME p INSULATION FIREPLACE = ELECTRICAL: ROUGH r,t FINAL ° PLUMBING: ROUGH FINAL GAS: ROUGH ' '" FINAL FINAL BUILDING ' DATE CLOSED OUT ASSOCIATION PLAN NOI,i , a 9 The Town of Barnstable . .t ' t.�►sysrnsix. II MAM Department of Health Safety and Environmental Services Eo ' Building Division 367 Main Street,Hyannis MA 02601 Office: 508-8624038 Ralph Crossen Fax: 508-790-6230 Building'Commissioner Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. t42A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. Type of Work: �A,46 &Z� ,1 Estimated Cost Address of Work: �IV Owner's Name: Date of Application: I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job Under$1,000 Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY { I hereby apply for a permit as the agent of the owner. Date Contractor Name Registration No. OR Date Owner's Name q:forms:Affidav 77ie Commonwealth of Massachusetts Department of Industrial Accidents ,� - ; �==�� Ofllct allmrestf,�atlods 600 Washington Sheet Boston,Mass. 02111 Workers' Compensation Insurance davit , ca scant �%%%%��%�4e .. MRIMIM e: location- City phone 0 ❑ I am a homeowner performing all work myself. I am a sole etor and have no one working in any a achy ❑ I am an employer providing workers' compensation for my employees working on this job. comounv name- address: city phone#: insurance en 2nllcv B ❑ I am a sole proprietor,general contractor, or homeowner(circle one)and have hired the contractors listed below who have the following workers compcnsation polices: .... .. com anv names address: dty. ... .<,:R.• .. ...... tee N •• insurance cn cam anv name. address• dtv nhune#: :,..• „�., ... ,..:.; .: :K:<..: a. . lieu 1!' 7, n3ars"CLI CO. ItesBuee to secure eoeerage as required under Section 2SA of 1IGL 152 can lead to the imposition oterimmai pmaitln of a Une up to s1,So0A0 and/or me yearn,huprisomnew as wall as dell penalties in the form of a STOP♦VORK ORDER and a du of 3100-00 a day ajamn me. I understand that a copy of this statement may be forwarded to the Otflce of Investigations of the DIA for tarrerase rert0c"10< I do hereby entity, under the pause a►d penakies of perjury that the information provided above is&w and correct: Signt►tttrt: Date - Ph=name Phase 0 oindal use only do not write in this am to be completed by city or town olfldal city or town: permumcense 0 Building Deparwaent �Lceavns Board ❑chnkif inunedlate respmnsa is required Oselectmen's Otste (]Health Department contact person. phone M. ❑Other UTVUM 9195 PJA1 Information and Instructions .; t� Massachusetts General Laws chapter 152 section 25 requires all emplovees to provide Nvorkers' compensation for their employees- As quoted from the "law",an employee is defined as every person in the service of another under any corgi- of hire, express or implied, oral or written. An employer is defined as an individual, partnership, association, corporation or other legal entity, or nay two or sore of die foregoing engaged in a joint enterprise..and including the legal representatives of a deceased employer, or the re».n-er . association or other legal entity, employ employees. However the owner of a rustee of an individual , partnership, house of dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling ...%„o.....l.,.n wren"¢to do maintenance , construction or repair work an such dwelling house or an the grounds 0: 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 renew of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who ha. not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commomvealth 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 coIIczctinQ authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and - supplvmg company names, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. Tile affidavit should be retumed 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 till 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 am in the event the Office of ptions has to contact you regarding the applicant. Please be sure to fill in the permW icease number which will be used as a reference number. The affidavits maybe it, ed f o the Department by mail or FAX unless other anaugcmeats have been made. The Office of Investigations would L1ce to thank you in advance for you cooperation and should you have any gaastions- please :a not hesitate to give us a ca1L The Dep rtmcm's address,telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents Ofnce of imresduadoas 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 eat. 406, 409 or 375