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g7 X1116 6J . � r�O. 152 113 ORA f' A TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 31. - Parcel jO Q 7 •--0 O i ' Application # �©`� oz .3 Health Division Date Issued �- Conservation Division ". Application Fee Planning Dept; :;;Permit Fee Date Definitive Plan'Approved by Planning Board G Historic - OKH Preservation / Hyannis cP_roject'lStreet"AddressT- r-Village- ' W F;S•r A R N S[A 3 L E COWnerx-JUDi TN T. \AIATF_Rr i EL1) rAddress. 3 `�-S \k)I L LOVJ ST '\oj, RN SEA 6C CTelepa e~ 508 - 342 - 4a4� crPermit-Request CD n64 N v Cf Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay *<-_P_oject Valuation,_ 9,6100 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 x 7 O 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`:-O Yes ❑ No 1 --0 :Z-= Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑-new size_ w � 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) Char eg. i UD i T H T, VIA�c��i C Li� Telephone'N� u mber» 5e)S - 3��- 60�}�s Address `1 'WILLOW S f R E FT. License # IAA, BAR 4 S I A 8 L E , HA . 62W,8 Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO (SIGNATURE ' If, & DATE-L-1 €� i3 S FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED ' `t MAP"[PARCEL NO. y _ ADDRESS. VILLAGE OWNER ` DATE OF INSPECTION: `-FOUNDATIONo — FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS.— ROUGH S".:c ,' FINAL -.- FINAL BUILD.ING!il° F OK �� y 7 _ -DATE CLOSED OUT 3> ASSOCIATION PLAN NO. i i i tt2t The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street a/ Boston, MA 02111 _4 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Bus J LY D T � T, vV A T I E L b Address_---, `7 S u1 ( L LD 1AJ S TI?t T City/, State/Zip- W) OIL— �Phone #: Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4.'❑ 1 am a general contractor and 1 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors 2. ❑ I am a so le.prop rietor or partner- listed on the attached sheet. t 7. ❑ Remodeling ship and have no employees These sub-contractors have S. ❑ 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 I am a homeowner doing all work right of exemption per MGL I LEJ Plumbing repairs or additions t m~yself.[No workers' comp. c. 152, §1(4), and we have no 12,❑ Roof repairs insurance required.j t employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and 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: Policy#.or Self-ins. Lie. #: Expiration Date: Job Site Address:. City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c: 152 can lead to the imposition of criminal penalties of a fine up to$.1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DLA for insurance coverage verification. 1 do hereby certify under the pains and penalties of perjury that the information provided above is true and correct. 7�sinature" � t—Date: ( onr'#— Official use only. Do not write in this area, to be completed by city or town offtciaL City or Town:. Permit/License# Issuing Authority(circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5, Plumbing Inspector 6. Other 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 foe 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/licease applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this"affidavit. The Office of investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 61 7-727-4900 ext 406 or 1-877-MASSAFE Fax # 617-727-7749 1 Town of Barnstable �pp'rHE rp�y y� 0 Regulatory Services BARNSTAsI-F- Thomas F. Geiler,Director Building Division PrED MPS a Tom Perry, Building Commissioner 200 Mairi•Street_Hyannis, MA 02601 R-ww.town.barnstable.ma.us Office: 509-962-403 8 Fax: 508-790-6230 FIOi\SOWNER LICENSE EXEMPTION Please Print --DATE:. W. I .I o l— TI( -JOB W.(1. 1� L q `Wks!r �AliVUOTA6LE number T �J street village �'HOMF.OW-NER_':-�_ VDi�� 11 �1�f1i�tL.� J��"-.�(p•Z'lQc.i�� name t� home phone# work phone# �CUR:RENf--MAIi:rNG=ADDRESS: �i�D r 60x 1 city/1Dwn state zip code Tlhe,current exemption for"homeowners"was extended to include owner-occupied dwelhn>s 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. DEFTTTIION OF HOMEOWNER Persons) 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 constMcts more than one home in a two-year period shall not be considered a bomeoymer. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building Official, that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned "homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned "homeowner"certifies that.be/she understands the Town of Barnstable Building Deparamcnt mir um.inspection procedures and requ.iremcnts and that be/she will comply with said procedures and requirements. atufe of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger wiIl be required to comply with the State Building Code Section 127.0 Construction Control. HOhIXOWNER'S EXEMPTION .The Code states that "Any bomcowner performing work for which a building permit is required shall be exempt from the provisions of this section.(Scotian 109.1.1 -Licensing of construction Supcnisors);provided that if the homeowner engages a prsson(s)for hire to do such work that such Homeowner shall act as supervisor."Many homeowners who use this rxcmptian are unaware that they are LssurTing the responsibilities of a supervisor(sce Appendix Q, Rulcs&Regu.)a6ans for Licensing Cmstruetion Supervisors,Section 2.15) This lack of awareness bfirn resvlu in serious problems,particularly when the homoowncr hires unlicensed persons. in this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responstblc. To ensure that the homeowner is fully aware ofhis/haresponnbilities,many communities require,as part of the permit application, that the bDMCOVlner certify that hc/gbc understands the rrsponnbilitics of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/rani fi cation for use in your con rununity. a Town of Barnstable Regulatory Services y urea. g Thomas F. Geiler,Director D )A. � Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-962-403 8 Fax: 508-790-623 Property Owner Must Complete and Sign This Section r If Using, A Builder e I , as Owner of the subject ro e P P rty hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for- (Address of Job) Signatum of Owner Date i Print Nurle If Property Owner is applying forperznitplease complete the Home owners'License Exemption. Form on -the reverse side. f I , Town of Barnstable Old Kings Highway Historic District Committee 200 Main Street, Hyannis; Massachusetts 02601 �PrEG ego (508) 862-4787 Fax (508) 862-4784 MINOR MODIFICATION TO PRIOR APPROVED PLAN 972 CMR Rules and Regulations, Section 1.03(2), 1.03: General Procedures (2.) (a.) Only minor changes may be approved by the Committee without the filing of a new application and a new.hearing. Minor changes include alterations that can be done without a detrimental impact on the overall appearance of the project such as altering a-single window or door change or a minor change of colors. All minor changes by amendment will require the local Committee's or its designee's approval. Submit 2 copies of the application and supporting materials and documentation Applicant(s), print name J 17 D ) T 14 T, WA TE F z . I Address of proposed work: y� l D 1A) 1 k k a Ih) 61' CT Ail y 1 cF /A)q NS EAe> iE— House No. Street Village Assessors Map and parcel no. 13 l — G a l C3 b f Date of approval of Certificate of Appropriateness Proposed Minor Modification: Construct- Q cav►��� ALirig,L�[�owr—D IIWVL- Town of Barnstable Old King's Highway _ m ee Signature of applicant: Print name: 4)0 h i rH '1 . WATE kF(r✓ 1-D tel no. �'OS -�loa- �6'lQ' f APPROVED/DISAPPROVED: signed CHAIRMAN DATE: CC: BUILDING COMMISSIONER Q:I GMD-Groups101d Kings Highway10KH New AppIOKH Minor Modification Form 07.doc 1 r .•mow ,� ,� ��� ��,m.c...,t � - - � � — --- ---- II, INN pow .IAI .nK ul r .a t 'I}w r r:'z�gCi.�c+-ya�}a�yg^.�wt�: li+. - � _ •.SM.'.. •�"��' - �. f. UJI Ix Cr �. Q �YU - ti v .vow.-•: K` r �•�r oZ R��� '�, C� Sc� �v f Rg MgSit �NTH�L hC ��H� _ �ri��t`',"a.!��`,�'`�''•r.Y'+�}` 3`?g w 116r4 S.-!� rev. tsOtKN�; IL) > Ocli c - L^r o LL Q 3�eC? X7 - g5 man , _ ;,, -- _ 7 <. 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'wr,jc7�t f.. .a � r• `�}� is • t i ). .* - r ---- -- T ......... -------- -------------------- , -- i All 'may PERMIT Town of Barnstable *Permit#,,�C�b �. i Expires ss months from issue date Regulatory.Services F t.e, : Z��g Thomas F.Geiler,Director Building Division �a trr' TO BARNSTAKE Tom Perry,CBO, Building Commissioner 64-1/1 200 Main Street,Hyannis,MA 02601. www.town.bamstable.ma.us Office: 508-8624038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY G ^ 7(90 ot Valid without Red X-Press Imprint Map/parcel Number L Property Address esidential Value of Work Mimmu ee of$2 .00 for work under$6000.00 wner's Name&Address r6 �jc( Contractor's Name Telephone Number�� � �G Home Improvement Contractor License#(if applicab(e) [ 's Compensation Insurance Check one: A-am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) side ❑ Replacement Windows/doors/sliders.U-Value (maximum.,A *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation',etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License is required. SIGNATURE: I f4l / i i QAWPFILES\F S\building permit forms\EXPRESS.doc Revise020108 1 D/�/IUAO David Sawyer Construction 318 Meiggs Backus Road Sandwich, MA 02563 (508)-539-1992 c `Proposal Submitted To: Work Place: Date�O �l - - 7 4d & �laln �' • Strip, Remove,. and Haul Away all old roof a o sidewall shingles. SUPPLY&INSTALL: COLOR: 61,E C5� ,.tALi ;�LG w,V-& CLEAN&REMOVE ALL DEBRIS FROM WORK PLACE AFTER JOB IS COMPLETED. ALL DEBRIS TO LANDFILL. i TOTAL INVESTMENT FOR MATERIAL&LABOR$�� ! V All material is guaranteed to be as specified,and the above work to be performed in accordance with the specifications submitted for the above work and completed in a subs ti l workmanlike manner. Payments to be made as follows r C� Any alteration or deviation from th or specifications involving extra costs ill be execu ed only upon written order,and will become an extra charge over and above the estimate. All agreements contingent upon strikes,accidents or delays beyond our control.Please remove and/or secure any fragile household items. Not responsible for broken or damage househol 'tems. 10YEAR LABOR WARRANTY/PLUS MANUFACTURES SHINGLE WARRANTY. This pro al may b wi awn by us if not accepted within 30 days. Respectfully submitted ACCEPTANCE OkfliOPOSAL The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payments will be made as outlined above. I &Izl6 dU Signature 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 .A licant Information lease Print Le bl Name(Business/Orr ganization/Individual): �+1/�t%(/o� �✓ ' Address: z �+ City/State/Zip: 1&0�- ,,11 2j hone.#: Are you an employer? Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the stab-contractors 2. I 'sole proprietor or partner- listed on the attached sheet 7. ❑Remodeling and have no employees These sub-contractors have g, E]Demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers' comp.•insu ance comp'tnsurance.t required:] 5. We are a corporation and its 10.0 Electrical repairs or additions � • 3.❑ I am a homeowner doing all work officers have exercised their l l.❑Plumbing repairs or additions myselL[No workers' comp. right 6f exemption per MGL 12 ❑goof repaiss ;ncnrance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that cheep box 01 must also fill out the section below showing their workers'cornpcasation 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. iContractws 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 subcontractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lilco# ( Expiration Date: Job Site Address: V V ✓y�� f JGIM '� I� `' -ty/State/Zip: / Attach a copy of the workers' compensation policy declaration page(showing the policy number and eaptration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fi tip to$1,500 00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine ne 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 c u der p and penalties of perjury that the information provided above is true and correct. Signature: Date: Phone# Official use only. Do not write in this area,tb 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/7own Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person:- Phone#: 1 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 fok the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es) and phone number(s) along with their certificate(s)of insurance, Limited Liability Companies'(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a'workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill in the permit(license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit on;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 bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call The Department's address,tmlephone•and fax number. The C6mmonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. #617-727-49,00 ext 4-0b or 1-977-MASSAFE Fax#617-727-7749 Revised 11-22-06 www.mass.gov/dia r Ate 'Commomtwald Board of Building Regula (ons and Standards One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement'Contractor Registration Registration: 134313 Type: DBA Expiration: 10/24/2009 Tr# 259907 DAVID SAWYER CONSTRUCTION' DAVID SAWYER 318 MEIGGS BACKUS RD. SANDWICH, MA 02563 Update Address and return card.Mark reason for change. DPS-CA Address Renewal Employment Lost Card 1 i'i SOM-0S/OCrPC��8490pp �/lle "[7pO7ym0'!ttl�EO�/L O���wGC�d . Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Board of Building Regulations and Standards Registration:"134313 One Ashbu lace Rm 1301,p Expiration: 16/24/2009 Tr# 259907 Boston, a.02 08 Type:, DBA DAVID SAWYER CONSTRUCTION DAVID SAWYER 318 MEIGGS BACKUS RD. SANDWICH,MA 02563 Administrator N slid withooelgnature Dann • .a .f 6 Town of Barnstable *Permit# E ts- I Expires 6 months from issue date :. - . . �v..... •. Re ulator - Services e seaNWre-er.Fn . . _ ... g Fee- p- mess _ � Thomas F • eil r,Director Building Division - _. ._ . --Tom Perry, Building Commissioner 200MainStreet,• Hyannis,MA02601-•••• APR -1 r 2005 •- Office: 508-862-4038 _ ::. TOWN-br� - Fax:•508-79.0-6230' -• - XP S : ER1i�iT pY;I A ON ='-RES11 ENTIAE ONLY. Not Yaiid.withoutRed X-Press Imprint Map/parcel Number Property Address esideutial Value of Work Minimum fee of$25.00 for work under$6000.00 Uv Owner's Name&Address i-- -! ��`� � '�• ` Contractor's Name �, �� ,�SdU rl NU t ' ^ TelephoneNumber ��I Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) Compensation Insurance CC �Worlanan's Comp �1 . \ vv C'�ece:soje ama proprietor ❑ I am the Homeowner ❑ e Workers Co ensation-Insurance I have ' mP Insurance Company Name \� Worlrinan's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(chec ox) e-roof(stripping old shingles) All construction debris will be taken to Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value ( =.44) ! *Where required: Issuance of this perrmt does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. *** ote: Property Owner must sign Property Owner Letter of Permission. N °p (� W Home Improvement Contractors License is required. x" - S Signature 0 Q:Borms:expmtrz Revise063004 • David Sawyer Construction 318 Meiggs Backus Road Sandwich, MA 02563 (508)-539-1992. Pros 1 Submitted To: Work Place: Date apout Strip, Remove, and Haul Away all old roof shingles. / SUPPLY&INSTALL: L„ .Gt,�I�C p m(/— ''AC 4- . n U G� 2�✓1G !'�wlall�� 0i I -TU *- pjxtm &VA-�L on ot S dy"d tj)X" CLEAN&REMOVE ALL DEBRIS FROM WORK PLACE AFTER JOB IS COMPLETED. ALL,DEBRIS TO LANDFILL. TOTAL INVESTMENT FOR MATERIAL&LABOR$ All material is guaranteed to be as specified,and the above work to be performed in accordance with the specifications submitted for the above work and complete in a , -rr substantial workmanlike manner. Payments to be made as follows P �R Any alteration or deviation from the work specifications involving extra costs will be executed only upon written order,and will become an extra charge over and above the estimate. All agreements contingent upon strikes,accidents or delays beyond our control. 10YEAR LABOR WARRANTY/PLUS MANUFACTURES SHINGLE WARRANTY. NOTE-This proposal may be withdrawn by us if not accepted wi days. Respectfully submitted _ ACCEPTANCE OF PRO d AL The above prices,specifications and conditions are satisfactory and are hereby accepted. You are.authorized to do the work as specified.Payments will be made as outlined above. 6 J I - WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY TYPE AR INFORMATION PAGE WC 00 00 01 ( A) POLICY NUMBER: (6KUB-8014A88—A-04) RENEWAL OF (6KUB-8014A88—A-03) INSURER: THE TRAVELERS INDEMNITY COMPANY NCCI CO CODE: 11347 1. INSURED: PRODUCER: SAWYER, DAVID R KERRY INS AGCY INC W 8 MEIGGS BACKUS ROAD PO BOX 1945 SANDWICH MA 02563 NORTH EASTHAM MA 02651 Insured Is AN INDIVIDUAL Other work places and identification numbers are shown in the schedule(s) attached. 2. The policy period is from 08-28-04 to 08-28-05 12;01 A.M. at the insured's mailing address. 3. A. WORKERS.COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident: $ 100000 Each Accident Bodily Injury by Disease: $ 500000 Policy Limit Bodily Injury by Disease: $ 100000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, listed here: SEE ENDORSEMENT WC 20 03 06 D. Tliis policy includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS — EXTENSION OF INFO PAGE 4. The premium for this policy Mill,be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 08-27-04 ML ST ASSIGN: MA OFFICE: ORLANDO INDUS AFF 161 PRODUCER: KERRY INS AGCY INC 28SHB aoeess WMI Board of Building Regula 'ons and Standards One Ashburton Place - Room 1301 Boston. Massachusetts 02108 Home Improvement Contractor Registration Registration: 134313 Type: DBA Expiration: 10/24/2005 DAVID SAWYER CONSTRUCTION DAVID SAWYER' _ 318 MEIGGS BACKUS RD. SANDWICH, MA 02563 Update Address and return card.Mark reason for change. � Qp Address [] Renewal Employment [] Lost Card y� T1."1009N/!)l [/b D�/l/LfLWOC/1Ll.00Qa . Board of Building Regulations and Standards License or registration valid for indhidul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Board of Building Regulations and Standards Registration: 134313 One Ashburton Place Rm 1301 Expiration: 10124mm Boston,Ma.02108 Type: DBA DAVID SAWYER CONSTRUCTION DAVID SAWYER 318 MEIGGS BACKUS RD. �� ,,i _ SANDWICH,MA 02563 Administrator Not vfdiftwi out signature 1 ' --" _ The Commonwealth of Massachusetts .= Department of Industrial Accidents Office oflnuest/gatlons 600 Washington Street, a Floor -- Boston;Mass. 02111 Workers'Com ensation Insurance Affidavit: Building/Plumb 1 /Electrical Contractors ��/ e name: VL'v (�� K�/J� ` i )c Q address: ,,► 1„I,��I/� ci �(L./UJ� state: ryVk_ zip- ]2L��)� hone# work site location full address): ❑ lam a homeowner performing all work myself. 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'���D rs r.. u.5 for:, ^•w�'�. ,w M•�r, ,r 1L15'Y�Iale..4�.$I...�,:l..:i:-:h:ti>.�..•.�4'.•iu:>Y.:;.♦..:..,....:a.... o}:,.:_•. `il--r.,':."..:.'.,._.. �'� . e - Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition otcriminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do here certify u der th pains and penalties of perjury that the information provided above is true and correct Signature Date Print name LPhone# official use only 7notwrite this area to be completed by city or town officialcity or town: permit/license# ❑Building Department' ❑Licensing Board ❑check if immediequired ❑Selectmen's Office ❑Health Department contact person: phone#; ❑Other (revised Sept i003) e 1 Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"law",an employee is defined as every person in the service of another under any contract of hire,express or implied,oral or written. An employer is defined as an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a . dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely,by checking the box that applies to your situation. Please supply company name, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance.coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,-not the Department of Industrial Accidents. Should you have any questions regarding the"law"or if = you are required to obtain a workers' compensation policy,please call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permittlicense number which will be used as a reference number. The affidavits may be returned to the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number:. The Commonwealth Of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street,71h Floor Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617)727-4900 ext. 406