HomeMy WebLinkAbout0395 WILLOW STREET .39.E .. - .
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CAPE COD TOWN OF BARNSTABLE
i
INSULATION 2013 JUN 10 AM 9: 5
MlU aLMS suMusf MATTO— W31-1a
!Ails auflU3 MUlAVON MUNaf
1-800-696-6611 DIVISION
Town of Barnstable
1' �g
Regulatory Services
Building Division 10
200 Main St
Hyannis, MA 02601
Date:
Dear Building Inspector
Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed &
completed the insulation and weatherization work at the property listed below. Cape Cod
Insulation did this in accordance to the specifications listed on the building permit
application. All work has been inspected by a certified Building Performance Institute
(BPI) inspector. All work preformed meets or exceeds Federal & State Requirements.
Property Owner Property Address Village
...f'V49A/ P/9,6'er 39SV GCvcv S7' t,J, %3/12N
Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrestricted
Ceilings
Slopes ( ) ( ) ( ) ( ) ( )
J
Floors ( ) ( ) ( ) ( ) ( )
Walls ( ) ( ) ( ) ( ) ( )
45 ti,e y (VOr e Je-0r.41<0l
Sincerely
I
VHry ssration,
sident
Insc.
i
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel' Application
Health Division ` Date Issued 31
ti
Conservation Division Application I*
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation/ Hyannis
Project Street Address Co'�r pN 71 S uAi-lloW Si'-
Village
Owner 94��'ejddress VW- f WOle
Telephone
Permit Request 9
.�s�AIL P " /2aa�1�,®d
f
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
i Project Valuation 6,04t 0®bnstruction TypeJ���r�
Lot Size Grandfathered: ❑Yes ❑ No If yes, attaohisupportingadocE�entation.
Dwelling Type: Single Family Z' Two Family ❑ Multi-Family (# units)
Age of Existing Structure Historic House: ❑Yes ®"No On Old Kings Highway: 03es 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 spew rn
Number of Bedrooms: existing _new
Total Room Count (not including baths): existing _new First Floor Room Count
Heat Type and Fuel: ❑ Gas ❑ Oil 0 Electric ❑ Other
Central Air: 0 Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No
Detached garage: 0 existing ❑ new size_Pool: ❑ existing 0 new size _ Barn: ❑ existing ❑ new size_
Attached garage: 0 existing ❑ new size _Shed: ❑ existing ❑ new size _ Other:
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
Commercial ❑Yes Q fjb If yes, site plan review#
Current Use y Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name e / u�� ,�i��[� Telephone Number ,-5'I ZZy_7� / 9L_
Address 4e4v421, z/;!g ,U� License # /G b q
Home Improvement Contractor#
_ Worker's Compensation # AJC 6 ,6
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
v
SIGNATURE DATE
r;
FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED
MAP/PARCEL N0.
a
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
FOUNDATION.
z
FRAME
INSULATION:
FIREPLACE
i ..
ELECTRICAL: ROUGH FINAL
"
PLUMBING: ROUGH FINAL
asf
:GAS:- ROUGH ,`!FINAL „
tFINAL BUILDING' :f
DATE CLOSED.OUT
ASSOCIATION PLAN NO.
The Co.minonwealth of Massachusetts
Y Department of Industrial Accidents
l` Office of Investigations
600 Washington Street
t� l Boston, MA 02111
ww)v.rn ass.go v/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant information Please Print Leaib!y
Name (Business/OrganiiatiorJlndividual):_ 1U_ A)
Address: C
City/Slate/Zip:
Phone #: 5-0 e -7 7 S—
Are you an employer'?-Check th appropriate box: Type of project(required):
1. 1 am a employer withQ_ 4 ❑ I am a general contractor and I 6 ❑New construction
eiripltiyees(full and/of'patt-time).* have hired the sub-contractors.,
2.❑ I axn 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.$
requ
5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ 1 amired.]a homeowner.doing all work officers have exercised their 11.0 Pltimbing 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' 13.0 Other(,i!eiz4 , I=J A t I r-
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 arc 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. tf.thc sub-contractors have employees,they must provide their workers'comp.policy number.
am an err•tployer that is providing workers' compensation insurance for my employees. .below is the policy and job site
informatiorL
Insurance Company Name:_ 14
— -V.(,Aar,
�o �i1
Policy# or Self-ins. Lic. #: (4) r7 S9 0 Expiration Date: (0 3G
� a� L
Job Site Address: rf/l�?(6�'S 9G(.L1_Tg g<- A l City/State/Zip:
Attach a cop), 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 $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
1 do hereby certify u e pa' and penalties of perjury that the information provided abo�ve�is trite and correct.
Date:
Si nature: l �
Phone#: 0
FOfficial use only. Do not write in this area, to be completed by city or town offieiaL
r Town: Permit/License#
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3, City/Town Cleric 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
t(Ogers. & Gray-.LCIs. rage: vie=
Client#: 4597 CCINSUL
ACORD.,. CERTIFICATE OF LIABILITY INSURANCE UA'rE(MIWUDIYYYYI
T7101/2011
HIS CERTIFICATE IS ISS I AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTAN :If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed,If SUBROGATION IS WAIVED,subject to
the terms and conditions of the polic y, certain policies may require an endorsement.A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsernent(s).
ehoUu—
Boyars s Gray Ins. -So. Dennis NAME:CONTACT Margaret Young
PHONE �....—.... ---434 Ruutc 134 ', Na• ) 508-760 4602
(ac No1 508-258-2102
P 0.box 1601 ADDRESS: Younglna@rogersgray,corn
R'DDD'CER
SUU(II Dennts, NIA 02660-1601 CUSTOMERIOs: --�
ZU e-T --- '--'---` INSURERS)AFFORDING COVERAGL NAIC 0 T---
Cape Cod Insulation Inc INSURERA:Peerless Insurance ^18333
455 Yarn'touth Road wsuRERs;Ohio Casualty Insurance Company
Hyannis, MA 02601 INSURER C:AtlanticCharterinsurance
M$URERD.Commerce Insurance Company 34754 —
IN5UKLK E
CGVtttA4cs INSURER F:
CERTIFICATE NUMBER: REVISION NUMBER:
1 rtls lS TO CERTi,-Y THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
u�ulG;l'Lti NOTWITHSTANDING ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
(aR II�ICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
AS
tn(.LUSIC)NS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
I tR TYPE OF INSURANCE POLICY EFF POLICY EXP
SR D POLICY NUMBER mwon Nw0DfYYYY LIMIT S
A GtNh1WLL1AiI1LlTY CBP8263063
0410112011 04/alf'2012 EACH UGGURRLNCE $1 OOU 000
X UtNtKAL I_IAtttl-I IY AA GETO RERTEO
1I --� PRCMI5- _5 e r $'I00 000
_—� 1.4,M1I;i w Dt �O(CVft meo exl-(Any onq polxn) $5 000
PERSONAL tL AOV INJURY $1,000,000
GENERAL AGGREGATE $2,000,000
l:.cN L.:i1JntCA'I'E 1,1NIIT APPLIES PER. PRODUCTS COMPoOP AGG §2,000,OOQ -
PULICY ILK I:
' LOC $
D Aut'or1rJBILt LIA ESILIT/ 11MMBCKVMK 4/0112011 0410112012 COMBINED SINGLE LIMIT
ANY AU10 (Eaaccidam) _ $1,000,000
_ ALL OVNED AUTOS' I BDOILY INJURY(Poe person) S ---
X 5CFm'DUL EU AUI'05 BODILY INJURY(Par accWanl) $ ^- _—
X lu en Urns I PROPERTVUAMAGE $
�• (Par ac idanl)
X rtUN•UVVNEI)AUTOS i - ^--`-=---
$
B urnnKCLLauAa X ocCUR 0001254514645 4101/2011 041011201 EACHOCCURRENCE $1000000
EXCESS LIAR CIAIMS-MADF. —'
.._ - AGGREGATE $1 OOO,OOO
OFDII(AIBLE --- --
I X Nrrrrniitry 10000 -----'---
C 'NUHKEH5 COMPENSATION 6/3012011 0 /31201 S FR
AND EMPLOYERS*uAatLn-Y WCA00525902 $
OTrIs
AN)PRUPK,tICK/PAR'I'NEi'vEXECUTIVE YIN EL.EACH ACCIDENT' $SQQ�QOQ
OFFICEWMEAIBER EXCLUDED? a NIA
Or4nonlury In NH) .—._
ea zi-crew unoor E.L.DISEASE-EA EhIPLOYEE $SOO;000
n+=SCRIPIIDN(�F(IPERAili)NS e4tw - _..__
E.L.DISEASE-POLICYLIMII' $50500
1-7
UL"MenON Ur UrEKA rI0N5 I LOCATIONS I VEHICLES(Attaen ACORD 101,Additional Remams Scnadoln,u more space is required)
Workers Comp Intormation Included Officers or Proprietors
(Sac Artached Odscriptions)
CERTIFICATE HOLDER CANCELLATION 10 Days for Non-Payment
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
009109) (01988-2009 ACORD CORPORATION.All rights reserved,
NS68575/M
ACORD 25(75/M68179 1 of 2 The ACORD name and logo are registered marks of ACORD
MEY
r—
� I
10 Park Plaza- Sulte 5170
Boston, Massachusetts 0211.6
Home Improvement Caractor Registration
_......._ . Registration: 153567
:._... Type: Private Corporation
....... . Expiration: 12115/2012 Trip 206433
... ........ ..
CAPE COD INSULATION, INC
HENRY CASSIDY
455 YARMOUTH RD.
HYANNIS, MA 02601
..;Update Address and return card. Mark reason for change.
Address ❑ Renewal Employment I-J Lost Card
at c7 >JYt-Ji.W-(ilO t:lo
uitice o� mcr Aflatrs us nr: Hngu► riou License or registration valid for irdiv;dcl use only
HOME fNfPRO( ff✓�k� �Cla before the expiration date. If-found return to:
`=a Registration: 153567 Type: Office of Consumer Affairs and Business Regulation
Expiration: 1,41512012 Private Corporation 10 Park Plaza-Suite 5170
Boston,MA 02116
OD INSUL�T)ON;`fIVC.,...
ENRY CASSIDY-.' ti+ '`:.... `:
55 YARMOUTH RD':
iYANNIS,MA O2 all Uudersecrcta -- -__
ry t alid ith t si ture
NIus-snchusr Ile,,.(Is- Dcli:u-tnl lit•Public
trfBuiltliu" ,� -
l�r. ul:ttinn., :ut(I ll:u1(l:(rtls
Construction Supervisor License
Licerlse:`CS 100988
Restricted to: 00
HENRY t y,
CASSIOY
S:S'hiETj N.
WV£ST-YARM TH, MA 02673 Y}
Expiration: 1 i/11/2011
- t.,nnnis.i..ncr
• T r�: 100988
l
9 y12
OWNER AUTHORIZATION FORM
(Owner's Name)
owner of the property located at
NO
(Property Address)
(Property Address)
C� C�Sv 'Q� ►a �
hereby authorize '
(Subcontract r
an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building
permit and to perform work on my property.
Owner's Signature
� o -
Date
I
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map 3 I Parcel 01`� Application # 6 /off <`
Health Division Date Issued 3
Conservation Division Application Fee -1tI-
,0�
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board ,(�✓
Historic - OKH _ Preservation/ Hyannis
Project Street Address 3 `�S c,��)/c�.� S •
Village (..,UeSt 1�rns-14b)e
Owner S y sa�n Pa y'l Le Address S T
Telephone
Permit Request
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation 41 Construction Type
Lot Size Grandfathered: ❑ Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family O' Two Family ❑ Multi-Family (# units)
Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No
Basement Type: Cull ❑ 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: a., existing _new
Total Room Count (not including baths): existing new First Floor Room Count
Heat Type and Fuel: O(Gas ❑ Oil ❑ Electric ❑ Other
Central Air: ❑Yes LrNo 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 s vsa/,-\ Rlrlle�(, Telephone Number
Address 3 q,� ��i tilo�' rt'' License #
(/0 4ScrhSfiP- ble, MA- O;LOr Home Improvement Contractor#
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO �u P
r
SIGNATURE DATE c3' �--
FOR OFFICIAL USE ONLY
tj
APPLICATION#
DATE"ISSUED
r MAP/PARCELNO.
ADDRESS 4n a h VILLAGE y
OWNER`-
DATE OF INSPECTION:
FOUNDATION
FRAME ..::
INSULATION
FIREPLACE
i ELECTRICAL: ROUGH FINAL
`PLUMBING: ROUGH FINAL
GAS: ROUGH -- FINAL
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO.__,
w
The Commonwealth of Massachusem
Department of Industrial Accidents
OjTwe of Investigations
600 Washington Street
Boston, MA 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le 'bl
NaIIle`(B�szness/Orga�atio'n/Individnan: �(�S � � v., �(��+ .
J _
S
Phone#: c� S
Are you an employer?Check the appropriate box:
4, k I mm a [7.
pe of project(required?: .
1.❑ I am a employer with general contractor and I
tmzployees(full and/or part-time).* have hired the sub-contractors ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet ❑Remodeling
ship and have no employees These sub-contractors have ❑Demolitionworking for me.in any capacity, employees and have workers'workers'comp.insurance comp.insn nce,J ❑Building addition
5• ❑ We are a corporation and its ❑Electrical repass or additions
�I am a homeowner doin all work officers have exercised theirg .❑Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12 Roof r
insurance raq=`Dd.]t c. 152, §1(4), and we have no ❑ ��
employees. [No workers' 13.❑ Other
comp.insurance required]
Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information
t Aommwners 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-conhaelars have employees,they must provider their workers'c policy number.
omp,p cy
I am an employer that isprovidbi workers'compensation insurance for my employees. Below is thepofuy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.# Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment; as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains andpenalfies ofperjwy that the informadon provided above is true and correct
Phone# !_'
Official use only. Do not write in this area to be completed by city or town official
City or Town: PermitUcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrica.l Inspector 5.E= -CtDr
6. Other
Contact Person: Phone#:
.. ,
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Town.of Barnstable
IKE Tp��
o� Regulatory Services
Thomas F.Geiler,Director
MASS
9� 039. Building Division
PIED MA'1 A
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
f ^ I Please Print
DATE
J'OB LOCATION:
number street village
-- "HOMEOWNER":
name home phone# work phone#
CURRENT MAILING ADDRESS: 1 i�n r— �/�
'�J "y� c 1 wID = V Y U� O "6
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and
to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as
supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is,or is intended to
be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A
person who constructs more than one home in a two-year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be
responsible for all such work performed under the building permit. (Section 109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes,bylaws,rules and regulations.
The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
req ' s7 ents.
0���,—\ j
Signatureof Homeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the
State Building Code Section 127.0 Construction Control..
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions
of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such
work,that such Homeowner shall act as supervisor." '
Many homeowners who use.this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,
Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly
when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed
Supervisor. The homeowner acting as Supervisor is ultimately responsible.
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,
that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by
several towns. You may care t amend and adopt such a form/certification for use in your community.
r
Q:forms:homeexempt
Town of Barnstable
ti
Regulatory'Services
` MASS. Thomas F.Geiler,Director
s� legs. �`�$
iOrFn�.I Building Division
Tom Perry;Building Commissioner .
200 Main Street,Hyannis,MA 02601
wwwAown.b arnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
r.
Property Owner Must
Complete and Sign This Section
If Using ABuilder
as Owner of the subject property
hereby authorize to act on my behalf,
in all matters relative to work authorized by this building permit application for:
(Address of Job)
Signature of Owner Date,
Print Name
If Property Owner is applying for permit please complete the
Homeowners License Exemption Form on the reverse side.
Q:FORMS:O WNERPERMISSION
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t Barnstable Old Kings Highway Historic'District Committee � � `��
1 200 Main Street, Hyannis,MA 02601, TEL: 508-862-4787 Fax 508-862-4784SLAM
r' '
APPLICATION, CERTIFICATE OF APPROPRIATENESS
Application is hereby made,with five(5)complete sets,for the issuance of a Certificate of Appropriateness under Section 6 of Chapter
470;Acts and Resolves of Massachusetts, 1973,for proposed work as described below and on plans,drawings,or photographs
accompanying this application for:
Check all categories that apply; a
1 1. Building construction: ❑ New ❑ Addition ❑ Alteration
►-3 i
2. Type of Building: El House El.Garage/barn El Shed ❑ Commercial El Other
+ 3. Exterior Paintina. roof ❑ new roof ❑ color/material change, of trim, siding,window, door Z
j 4. Sig_: ❑ New Sign ❑ Existing Sign ❑ Repainting Existing Sign �' t?i
' O O
5. Structure: ❑ Fence ❑ Wall ❑ Flagpole ❑ Retaining wall ❑ Tennis co -04 er 4 `
t=J i
6. Pool ❑ Swimming ❑ Other man-made pool ❑ Solar pane �Other
E
1 = 1 t
Type or Print Legibly: Date
NOTE AU applications must be signed by the current owner i
o T Owner tint r 1 ('
of m "� (print): 'J GL V1 0. �� �I'; Telephone#: f. sag 3 a' $SS yft n
318 o Address of Proposed Work: ��S I o W �� Village 0f� crr„s t' Map Lot#
U;0
? O Mailing Address(if different) •a 0-Kg
CD
EY
N Owner's Signature
Description of Proposed Work: Give particular4'of wok to be o ��r' �elq^ All i ' ,
1
Agent or Contractor(print): "0 Q` Tele hone#: J V Is--- Cl
Address: f :•� : °;'
kri-•
"9
Contractor/Agent' signature:
l For committee use only. This Certificate is hereby APPROVED/DENIED
Date Members signatures
CERTIFICATE OF APPROPRIATENESS SPEC SHEET Please submit 5 copies i
Foundation Type:(Max. 12"'exposed)(material-brick/cement,other)
y i
Siding Type: Clapboard,*_ shingle_ other
Material: red cedar white cedar other Color:
- t
Chimney Material: Color:
Roof Material: (make&style) Color:
Roof Pitch(s): (7/12 minimum) (speck on plans for new buildings, major additions)
Window and door trim material: wood other material, specify
RECEIVED
Size of cornerboa�s size of casings(1 X 4 min.) color
JAN ;
Rakes Ist member 2°d member ' Depth of overhang
Window: (make/model) • material color GROWTH MANAGEMENT
(Provide window schedule on plan for new buildings, major additions)
Window grills,(please check all that apply_:
t
true divided lights_ exterior glued grills— grills between glass_removable interior None-
Door style And make: material Color:
• r
Garage Dopr,Style Size of opening Material Color
Shutter_Ty&/Style/Material: Color:
f
Gutter Type/Material: Color:
Deck material: wood other material,specify Color: i
t1' AA �ICm YYl4r►�a� VeK} :r�4 1/I �I
Skylight,type/make/modelh ye��y x material - Color: Size: D la )( `t(, J� f
Sign size: Type/Materials: Color:
Fence Type(max 6')Style material: Color:
Retaining wall: Material:
Lighting,freestanding on building illuminating sign
OTHER INFORMATION:
THE ATTACHED CHECK LIST MUST BE COMPLETED AND SUBMTITED. -
Please provide samples of paint colors,manufacturers brochure of windows,doors;garage door,fences,lamp,posts etc
APPRO Y-ED . �f
Signed:.(plan preparer) Print Name $
" FEB 2 2 2M
Towri.of 6atn�m
QABoa"andConuntrsJons101dKlggsHighwaylOKYAppllca6l w10KH2011 CertApproprbteness.dac Old'#�<i/t7�g� tt F V81E r
5. SIGNS
Diagram of sign, showing graphics, size, design and height of post,color and materials. d
i Spec sheet. p
Site Plan on a GIS ma or mortgage surve OR photographs i pY� p graphs OR to-scale sketch of building elevation
showing location of proposed sign; and any tree to be removed near a freestanding sign.
t Fee according to schedule. N
rrJ
Z
6. SOLAR PANELS � •� o �
Drawing of location of panels on house showing roof and panel dimensions. 0
Site plan showing location of building on property. (Assessors map may be submitted) m
Height of solar panel above the roof. 07,B 00
Color of panels
Finish(matt or glossy) 3= *-3
i mc�u�i N
� O
Ufa N
7. FOR LIST OF ABUTTERS: PLEASE SEE OKH STAFF
SIGNED (plan preparer) m1, Print n Rr ICe r
Date: `` `\� Tel. Phone no's:
NOTE
The Old Kings Highway Historic District Committee MAY DENY INCOMPLETE APPLICATIONS
ATTENDANCE AT MEETINGS: If the applicant or his/her representative is not present during the hearing is scheduled, the application
may be either CONTINUED OR DENIED 1
APPEAL PERIOD APPROVED PLANS PLAN PICK UP I
There is a ten(10)day appeal period,plus a 4 day waiting period for approved plans from the date the decision is filed
with Town Clerk. This is necessary for etch Certificate of Appropriateness and/or Certificate for Demolition issued by the
Old King's Highway Committee. Plans approved by the Old King's Highway Historic District Committee may be picked up
at Growth Management,Regulatory Division,200 Main Street,Hyannis,after expiration of the 14 day `wait period. If the -
14"day falls on'a Saturday,your plans will be available the afternoon of the following business day.
DENIALS
Applications that are denied may be appealed to the Old Kings Highway Regional Historic'District.Commission
within 10 days of the filing of the decision with,the Town Clerk...-For more information, see•the Bulletin of the Old -
Kin s Hi wa District Commission. _
BUILDING PERMITS, OTHER AGENCY CONTACTS
In most instances, before commencing work,a Building Permit is required. The Building Division will require a
certified plot plan for new construction and/or demolition. Commercial work may require Site Plan approval.
Demolitions: the applicant should check with the Building Division as to conformance with ZoninLy renuiremP„t,.-
Model VCE Electric venting skylight
• Package Includes the remote KLR 100 and Insect •Single hard wire connects Into a standard Junction box.
screen. VCE can be Installed flat at a 0'roof pitch. gr
• White maintenance free frame and sash. 0'_600
0:12-20:12.
Inside curb in. 221/z x 221/z 221/z x 341/z 221/z x 46V 301/1 x 301/2 30'/x x 46'/z 341/z x 341/: 461/:x 46'h
. 53112 �
251/zx251/:~ `251/zx371/: 25Vzx r%iz33z/z 33'/zx49z/: 37y:x371h 491/zx493/:' e
Max.skylight clearance` in. 261&x269h6 269/6x389/4 269/6x501 341Aux349A6 349/ux509/z6 389A6x389/m 509A6x509A6 x Z txj
N L�
Model VCM Manual venting skylight �? c
• Package Includes the operator hook and Insect screen Optional VELUX control rods available for out-of-reach N
• White maintenance free frame and sash. manual operation. 00-fiU°
VCM can be Installed flat f p h.
0:12-20:12
is
i
insidecurb In. 221/2x221/z 221/2x341/2 r 221/2x461h 30y:x3oV, 301/zx4W/z 341/2x341/2 461hx46%
i ut3lde.cilrb in. 251h x 251/1 25%x RV, 25 V,x zx331/2 331/2 x 491/z 371/2 x 371/, 49'/z X 491/z
1+' Max.skylight clearance In. 269%x269A6 26°%x38°/u, 261%ex50V 1/14x349h6 349/.x509/`� 381/mx3V& 50V.,x50V.
1 00 —M
a �p
. Model FCM Fixed skylight o IX v
• No designated top,bottom or sides to allow installs impact and Miami Dade variants are available for to
In any direction. hurricane prone areas.® o C ?Wide range of custom sizes available. •White laminated glass available for applications where 0 -60 uz. fV
diffused lighting Is required. 0:12-20:12 0 ��qq
I<CD N 111
14� .
Si7e code
s'
s
~ 141/2 x 141/2 x 221/2 x 221/2 x 22 22yzx 221/z x 301/2 x 301/2 x 341h x 461/z z
Inside curb in. 301/2 461/2 221/2 301/2 34 4by: 70'/2 301/2 461/: 341/z 461/z
r In. 171�2X 1711zX 25z�zx 25z�:x, i 251izx 3311:X 331/:x 371�z7( 49'izx
33/z 49/z 25/z 33/z ri 73/: 33/: 49/: 37/r 49/z y
Max.skylightclearance In. 181/8x 181/0X 26Vax 26Vax y 26'd ays/ex 26a/ex 34IAx 345/ex 36°/ex 505/ex~
34% 50% 26ah 34 a/' 38 i01/6 74 e% 34 ah 50 e% 38 a/e 50 a/e
50 VELUX www.veluxusa.corn 51'
•R.ECETITED
APAw
���
GROWTH MA:�A(-'EMEN7"
Kind's hiyhw,�
Boom
k
box•-ea
5
Town of Bamstable Geographic.lnformatlon System February,6,2012
13103-
*11
131032
s3a3
• s
238
131018 �
131003 0365
0283
131018
•228
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ss S1 0400
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• ��.Z19 Me �P� 130009
90
0 56 Feet 13000s 130is
DISCLAIMERS:This rtup is for pbMft puhxxm o*. It is nol adequate for lagal map:131 Parcel:017 o
boundary datem ination or reguiatory Intarpralation. iniargamand r. ER boys !a scale of Owne PARK SUSAN E Total Assessed Value:$389300 Selected Parcel'
1'.100 may not most estaDllahed map Kauacy etanderda The parcel ones on thismap
an only graphic mpress of Assessor's tax parcels.They are not true propwty Co Owner AcreaQe:1.18 Haas Abutters
antatlon
boundaries and ao nd roprasard accurate relationships to physical features on Iha map Location:395 WILLOW STREET Buffer /
such as buti�ng tocaticna.
^ F
CAPE SAW D -k r j-
Weatherization
508-3,98-0398
December 14,2011
Town of Barnstable
Thomas Perry CBO
Building Commissioner
200 Main St. Hyannis, MA 02601
RE: Building Permits
Dear Mr. Perry,
This affidavit is to certify that all work completed for permit application #201102300, Status A,
Parcel 131017 at 395 Willow Street,West Barnstable,Permit type: RADD, and issued on
5/16/2011 has been inspected by a certified Building Performance Institute (BPI) Inspector. R-18
Cellulose insulation was added to the attic. Walls were dense packed with R-13 cellulose
insulation. Basement sill was insulated with R-19 fiberglass batts. Basement perimeter was
wrapped with R-5 reinforced foil or vinyl faced ductwrap.All work performed meets or exceeds
Federal and State Requirements.
Sincerely,
William McCluskey
I
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map I L3 1 Parcel Application f# ��O O
Health Division Date Issued
Conservation Division Application Fee
y
Planning Dept. Permit Fee [ ��
Date Definitive Plan Approved by Planning Board
Historic - OKH Preservation / Hyannis
Project Street Address , 3 9 5 MI i J� ow S�
Village �1�1es-t l�a(' e
Owner ar P.r Address sa.M e
Telephone 5 0? -3 t. - 3�55
Permit Request C'e_)) sw- :to ee->> ,n ( ovPC) A :]Z&S
�a io y e-v►-i- an Qn° cpo r-v►-t + t',C, st evL-t i C i�� yin • /��'r � � ate-«
v\&Vie a3 ^,0 M �GY +�� E J1fG sf'�' cas tt I SI�D� .9' � �'O f�'1/ 1 (J� e��'►nn�t-ter
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation 5.000. 00 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 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 .0 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# c ��
Current Use Proposed Use
APPLICANT INFORMATION
(BCUILDER OR HOMEOWNER)Name wl 1m G� �ct �Ja� Telephone Number 5 o a 9 R + 0,3 7Q
Address 7,0 404 11 License # �--� 0 a, b
yopmnkl+h , 1' o;luq Home Improvement Contractor# I 6 031
Worker's Compensation # 7 / ® / 5
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO
SIGNATURE DATE
'4
FOR OFFICIAL USE ONLY
°i
`APPLICATION#
DATE ISSUED
MAP/PARCEL N0.
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION: ;
r
FOUNDATION
FRAME
INSULATION y
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS; ROUGH FINAL
FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO.
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
Analicant Information Please Print Legibly
Name(Business/Organization/Individual): I t^ ' t✓i A&C-14i,svett DII131& C46C SAUG
Address: -C, UPS I N(.-lb� �1
City/State/Zip: • YAa MOSL l 6?-U 9one#: "i - 3 g- 3
Are you an employer?Check the appropriate box:
. I am a general contractor and I Type of project(required):
1.[K I atn a employer with� 4 ❑
-
employees(full and/or part-time).
have hired the sub-contractors 6. ❑ New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. [] Remodeling
ship and have no employees These sub-contractors have g, ❑Demolition
working for me in any capacity. employees and have workers' q 0 Building addition
[No workers' coinp. insurance comp.insurance.*
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 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]t e. 152,j 1(4),and we have no t '
employees. [No workers' 13.® Other-S nSJ c�, i Jf)
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 ase doing all work and then hire outside contractors must submit a new affidavit indicating such_
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. lfthe 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: I^LAM S (I 1 S Lk tear I\J Ctr
Policy#or Self-ins.Lic.M lam-+C- 9 S Expiration Date: Z
Job Site Address: c� / 5 w-1 I)0W IS+' City/State/Zip: 0 ml'T 11 10 b g
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains And Penafties erjury that the information provided above is true and correct.
Signature:- r Date: 3
Phone#: � - �S
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
is
'4co CERTIFICATE OF LIABILITY INSURANCE DATEiMM/ODIYYYY) -
11/1J2010
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED,subject to
the term 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 endorsetnent(s).
PRODUCER CONTACT
)SAME: Shannon Sperrazza
-
R1aIS Strategies Company PHONE (761)986^4000 ,F�ACx . (781)963-aG2D
15 Pacella Park Drive f*L .seperrazza@risk-strategies.com
Suite 240 PRODUCER 90018476
Randolph MA 02368 INSURERS AFFORDING COVERAGE j NALC#_
INSURED INSURERA:Seneca Specialty Insurance Co
INSURER B Aeating Group Ins Services
Michael McCluakey, DBA: Cape Save INSURER c4Chartis insurance
7 C Huntington Ave INsuRFJ2 0: --
INSURER E:
South Yarmouth MA 02644 INsuRERF: -
COVERAGES CERTIFICATE NUMBER:CL1011132675 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED A80VE 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.
LLTR. TYPE OF INSURANCE A i POLICY NUMBER MMI PCIUCY E I MMIDD/DIY YY LIMITS
GENERAL LIABILITY EACH OCCURRENCE '$ 1,000,000
COMMERCIAL GENERAL LIABILITY i
30/16/2010 S0/16/2011 PR Meocarrence) $ 50,000
A E CLAWS-MADE :R OCCUR 8AG1002608 -T
MEO EXP(Any one person) $ 10,000
i PERSONAL&ADV INJURY i$ 1,000,000
GENERAL AGGREGATE $ 1,000,0001
,_GEN'L AGGREGATE LIMIT APPLIES PER: i
r— ? PRODUCTS-COMPIOP AGG ;$ I. QOO,Owl
i X'POLICY :PRO-JECT LOC j $ - - --"
i AUTOMOBILE LIABILITY .COMBINED SINGLE LIMB $ 1,000,000
ANY AUTO I6208200 11/6/2010 'll/6/2011 I(Eaeccioenl)
BODILY INJURY(Per person) Is
1--:ALL OWNED AUTOS ( BODILY INJURY(Per eccidem)i$
X' SCHEDULED AUTOS
-- HIRED AUTOS I i PROPERTY DAMAGE
R
I(Per sodded)
t X;NON-OMMED AUTOS '
$
1 ' i
i R 'UMBRELLA tJAB :OCCUR ` EACH OCCURRENCE ?$ 1 O00 OQO
D(CE58UA8 �J CLAIMS-MADE I f I AGGREGATE $ 1,000,000
DEDUCTIBLE
B I RETENTION $ 23578601 }0/16/2010 10/i6/2011: $
C WORKERS COMPENSATION
i kdichael McCluskey i I WC STATU iOTH
;
AND EMPLOYERS'LIABILITY Y N . j I !X'TORY LIMBS' ER
ANY PROPMETOR1PaRTNERIEXECUTIVE t i its excluded from coverage; E.L.EACH ACCIDENT $ -
1 OFFICER(MEMBER EXCLUDED? a I N!A i i 500 000
(MendatoryinNH) 19930951 :10/21/201010/21/2011: 500 000
K ygs,deeaibs � 1 •E.L.DISEASE-EA EMPLOYES$
DESCRIPTION OF OPERATIONS below i El DISEASE-POLICY LIMIT $ 500L000
1 i
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,it more space is required)
Issued as evidence of insurance. Contractors-Executive Supervisors or
EEeautiVA Superintendents.
CERTIFICATE HOLDER CANCELLATION
(508)790-2425 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Housing Assistance Corp ACCORDANCE WITH THE POLICY PROVISIONS.
Attn: Ruth
460 West Min street AUTHORIZED REPRESENTATIVE
Hyannis, MA 02601-3698
?Iichael Christian/SMS
ACORD 26(2009109) ®1988-2009 ACORD CORPORATION. All rights reserved.
INS025 poosias) The ACORD name and logo are registered marks of ACORD
Office of Consumer Affai s and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 164432
Type: Supplement Card .
CAPE SAVE Expiration: 10/6/2011
WILLIAM MUCCLUSLEY ___._..____... ... ... ..
8201 S. HOURD CT
CHAPEL HILL, NC 27516 _..___.__................ ..._
Update Address and return card.Mark reason for change.
Address '"- Renewal Employment Lost Card
t. ../,,3 2CL•/Nf!!il'!P(f'fj:ljl ��.. !/U:.}!:!�l!{�`;
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
before the expiration date. If found return to:
HO#IE IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation
'+ Registration: 164432 Type; 10 Park Plaza-Suite 5170
Expiration: t0/6/2011 Supplement Card Boston,MA 02116
CAPE SAVE
WILLIAM MUCCLUSLEY -
X HUNTING AVE.S.YARMOUTH,MA 02664 Undersecretary Not valid wi ou signature
DvIlactnk-np #)I pill-sli: "A.AL.1 c.
tlilildin; itv_,rlatinR!, .Uiit �i,rrril: ?AN
Lic?nse: ;S Si. 102776
Restricted vu; IC
WILLIAM MC CLUSKY
37 NAUSET ROAD `.
WEST YARMOUTH, MA 02673 -
�—
08/25/2010 09:23 9193212955 PAGE 01i01
A
CAPE . SAVE
1
Wearnerization
508-398-0398
August 22, 2010
To Whom It May Concern:
William J. McCluskey is an employee.of.Capg.Save. He is authorized to negotiate
contracts and building-permits for our.company.
!Michael McCluskey
Cape Save—Owner
919-593-5939 cell
7C Huntington.Aven",,South Yarmouth,MA 02664
460 VTes Valn Street
HOUSING Irivatims, M" 02601-'698
ASSISTANCE lzNE11(",'Y H01VIE REPAIR
T "508) 77 1-5400 F (.S0S)790-2425
CORPORATION on Lill lr'ne�
HOME OWNER WEATHERIZATION WORK PERMIT& FUEL RELEASE:
PLEASE FELL OUT AND SIGN TMS FORM IF YOU ARE
THE APPLICANT HOME OWNER.
I hereby consent to and agree that weatherization work may be
done by the Weatherization Program of Housing Assistance Corporation( herein after referred as
"Agency")on the property located at:
weatherization work done will be based on programmatic priorities and availability of funding and
it may include all or some of the following measures:
Weather-stripping&caulking of windows and doors,insulation of attics,sidewalls &basements, attic
and other ventilation measures and possibly replacement of badly deteriorated windows.In
consideration of the weatherization work to be done at my home.1 agree to the following:
1. 1 give permission to the "Agency" its agents and employees to travel onto-or across said
property with such equipment and materials as may be necessary to perform weatherization
work on said property.
2. The Housing Assistance Corporation reserves the right to inspect the fuel or utility bill for the
weatherized unit on an ongoing basis for no more than five (S)years after the weatherization
work is completed.
I have read the provisions of this agreement as 1i and freely give my consent.
Home Owner: (Signature. j
Date: L<>i i
Agent: (signature) . ......
Date: q 1/7 fhol I
HAC approved Wcatherization Company: Cc` e_ Sow(-
Caliber Building&Remodeling Cape Cod Insulation ape Save Creswell Construction
Frontier Energy Solutions Lohr&Sons Peter Smith Resolution Energy
Rock Solid Construction All Cape Insulation
i
xfr 6o13
rtHE Tayy Barnstable Old Kings Highway Historic District Committe-e
O�
200 Main Street, Hyannis, MA 02601, TEL: 508-862-4787 Fax 508-862-4784
ql
TfnMa�a APPLICATION, CERTIFICATE OF APPROPRIATENESS
Application is Hereby made,with four(4)complete sets, for the issuance of a Certificate of Appropriateness under Section 6 of
Chapter 470,Acts and Resolves of Massachusetts, 1973,for proposed work as described below and on plans,drawings,or
photographs accompanying this application for:
Check all categories that apply;
1. Building construction: ❑ New ❑ Addition Alteration
2. Type of Building: ❑ House ❑ Garage/barn ❑ Shed ❑ Commercial ❑ Other
3. Exterior Paintiri , roof ❑ new roof ❑ color/material change, of trim, siding, window, door
4. Si n : ❑ New Sign ❑ Existing Sign ❑ Repainting Existing Sign
5. Structure: ❑ Fence ❑ Wall ❑ Flagpole ❑ Retaining wall ❑ tennis court ❑ Other
6. Pool ❑ swimming ❑ Other man-made pool
Type or Print Legibly: Date: l proposed c� Address ro osed work: House# i�$
Street: (� S T Village 00,Berns Assessors Map Lot
Description of Proposed Work: Give particulars of work to be done:
, 1`r4 tLc�c'e,S c��1 1-(06 hSAD ws"
Agent or Contractor(print): Telephone#:
Address:
Contractor/Agent'signature:
NOTE All applications inust be signed by the urrent mpner
Owner(print): S LSa r\ �.�Il et Telephone#: �p� /�' j C)d
Owners mailing address:
Owner's signature: c3•�
For committee use only. This Certificate is h y A.PPitO'VED/DENIED
DE C E Date _ � __ Members signature"_-5q-g
TOWN OF BARNSTABLE
HISTORIC PRESERVATION _} A ons of approval
1
C:Documents and SettingsldecolliklLocal SettingslTemporary Internet FileSIOLKI IOKH Cert Appropriateness 07.doc
!j ,Ej
'
TOWN OF BARNSTA___
Town of Barnstable Old King's Highway Regional Historic Distri t (MML itl'e;3RESERVA Ti
CERTIFICATE OF APPROPRIATENESS SPEC SHEET —�
Please submit 4 copies
Foundation Type: (Max. 18 exposed)(material -brick/cement, other)
Siding Type material: Color:
Chimney Material: Color:
Roof Material: (make& style) Color:
Trim material Color:
Roof Pitch: (7/12 minimum)
�y
f MI _ `l
Window: (make/model) F\cQQ' �ca•'� �(�O material Ui r\.y1 c��� color t���`` , oC/�
Sizes) �n��•c-zr�� c�S� L�,C'i-h SGuvtp-' S1'2e� ; SC.".C-Tri rn.l
Door style and make: material Color:
Garage Door, Style Size Material Color
Shutter Type/Material: Color:
Gutter Type/Material: Color:
Decks: material Size Color:
Skylight,type/make/model/: material Color: Size:
Sign size: Type/Materials: Color:
Fence Type(max 6 )Style material: Color:
Retaining wall: Material:
Lighting,freestanding on building illuminating sign
r
Please provide samples of paint colors and manufacturers brochure of style of windows,doors,garage door,
fences,lamp posts etc
ADDITIONAL INFOR1dIATION:
Signed: (plan preparer) print name
tel.no. Location of application: Street no.
Street Village
2
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-
e
°FYI r Town of Barnstable =Permit#
LrpireA 6 months from issue date
Regulatory Services F
BAartsrABLY,
MAC $ Thomas F. Geiler,Director
1639• -
p�fD
Building Division
Tom Perry, CBO, Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number
Property Address 01,<-- (,,J jL D�j S f� 4-A) Goa
esidential Value of Work O O •c?'� Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address
Contractor's Name Telephone Number
Home Improvement Contractor License#(if applicable)
+ Construction Supervisor's License# (if applicable)
❑Workman's Compensation Insurance -PRESS PERMIT
Check one:
❑ I am a sole proprietor JUL 14 2010
FIam the Homeowner
have Worker's Compensation Insurance TOWN OF BARNSTA9 E
Insurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
❑ Re-roof(stripping old shingles) All construction debris will be taken to
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re ide
0 _C_J_s�'� b� S�-r I #of doors
eplacement Windows/doors/sliders.U-Value (maximum .44)#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
uired. �
ckk-
SIGNATURE:
0:\WPFILES\FCRtvlS\building permit forms\EXPRESS.doc
The Commonwealth of Massachusetts
Departrnent of Industrial-Aceidents
Office of Investigations
600 Washington Street
Boston, MA 02111
wivw.mass.gov/dia
Workers' Compensation Insurance Affidavit: builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
C Sr
I Name (Business/Organization/Individual): I
Address: - C.
City/State/Zip: (� �'° `L Phone #:
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time),* have hued the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
worki g for me in any capacity. employees and have workers' 9 ❑ Building addition
[N workers' comp. insurance comp.insurance.
quired.] 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
_rnyself,..[No Workers.'-eoznp,.....-_-_.-.........,.......right of exemption per MGL - ❑Roof.repairs...........
12. -
r insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ 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 state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that isproviding workers'compensation insurance for my employees. Below is thepolicy andjob site
information.
Insurance Company Name:
Policy#or Self-ins..Lic.M Expiration Date:
Job S.ite 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 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
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is trite and correct.
Si nature CAr�� Date• �-�"
Phone#•
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority (circle one):
1. Board of health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6. Other
Phnne#:
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 tnistee of an individual,partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair.work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer.'
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7) states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractors)name(s),address(es)and phone number(s) along with their certificate(s) of
insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships (LLP)with no employees other than the
members or partners,are not required to carry workers compensation insurance. If an Li C oi'LT P 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 maybe 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,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 4-24-07
www.mass,gov/dia
r
��oFay
Town of Barnstable
tKE r
„�. o Regulatory Services
BARNsrwst.e. : Thomas F. Geiler,Director
�P 16.9. s•0� Building Division
lFn µai
Tom Perry,Building Commissioner
200 Main.Street,. Hyannis,MA.02601.
www.town.barnstable.ma.us
Office: 508-862-403 8 Fax: 509-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE: � =
JOB LOCATION:
number street( village
"HOMEOWNER": �C>SCN� 0.1^1Lez
name home phone# work phone#
CURRENT MAILING ADDRESS: d7C a-j
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and
fo allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as
supervisor.
DEFTNMON OF BOIVIEOWNER
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 constrgcts more than one home in a two-year period shall not be considered a bomeovmer. 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 perforated under the building permit. (Section 109.1.1)
The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other
applicable codes, bylaws,rules and regulations.
The undersigned"homeowner"certifies that.he/she understands the Town of Barnstable Building Department
minimum inspection procedures and requirements and that he/she will comply with said procedures and
requirements.
Signature of Homeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the
State Building Code Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
.The Code states that "Any homeowner performing work for which a building permit is required shall be exempt from the provisions
of this scction.(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such
work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,
Rules&Rcgblations for Licensing Construction Supervisors,Section 2.15) This lack of awareness bficn results in serious problems,particularly
when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed
Supervisor. The homeowner acting as Supervisor is ultimately responsible.
To ensure that the homeowner is fully await of his/her responsibilities,many communities require,as part of the permit application.,
that the homeowner certify that helshe understands the responsibilities of a Supervisor. On the last page of this issue is a.fmn currently used by
several towns. You may care t amend and adopt such a fom✓certification for use in your community.
Q:fomu:homeexempt
aa
S
'THE I-, Town of Barnstable
Regulatory Services .
BARNSTARLFMAM Thomas F.Geiler,Director
'�Enr '` Building Division
Tom Perry, Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-403 8 Fax: 508-790-6230
Property Own Must*
Complete and Sign his Section
If UsingA wilder
as Owner of the subject.property
hereby authorize to act on my behalf,
in all matters relative to work auth ' d by this building permit application for.
Address o ob)
Signature of Owner ate
Print Name ;
If Property Owner is applying for permit please complete.the
Homeowners License Exemption Form on the reverse side.
Q:F0RMS:0 WNERPERMISS10N
;
� r
01.1KE Town of Barnstable *Permit# oo�C�q�S
Fxpires'6 uionthsjro is ate
Regulatory Services Fee
BARNSTABLE, Thomas F. Geiler,Director
y MASS.
1639. .�A Building Division
rED MAI 't A
Tom Perry, CBO, Building Commissioner
200 Main Street,Hyannis,MA.02601
www.town.bamstable.ma.us
Office: 508-862-4038 Fax: 508-700-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL; ONLY
Not.Valid without Red X-Press Imprint
Map/parcel Number 1 V
Property Address 3 CIS— L ) ; 1 o,,.j S T
EgResidential Value of Work ,t O O o Minimum fee of$25.-00 for work under$6000.00
Owner's Name&Address SJSrv\ 1Pri6e.1-
Sl- (JJ . f3�r —� b) e �tii
Contractor's Name Telephone Number 57��. 3 6
Home Improvement Contractor License#(if applicable)
❑Workman's Compensation Insurance
Check one:
❑ I am a sole proprietor ��
I am the Homeowner �e�� � �ER
❑ I have Worker's Compensation Insurance
Insurance Company Name FEB — 4 2009
Workman's Comp. Policy# TOWN OF BARNSTABLE
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
❑ Re-roof(stripping old shingles) All construction debris will be taken to
❑Re-roof(not stripping. Going over existing layers of roof)
❑ Re-side
Replacement Windows/doors/sliders. U-Value (maximum.44)
*Where required: Issuance of this pen-nit does not exempt compliance with other town department regulations,i.e. Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License is required. .'„ 0� .ItiQ
90 NJ
SIGNATURE:
Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc
Revise020108
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations-
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): S LIsc v-\,
Address: 3gS
City/State/Zip: ("o , 02>ar-ng-ta(ok_ Phone.#:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2:❑ I am a sole proprietor or partner-' listed on the attached sheet. 7. .❑Remodeling
ship and have no employees These sub-contractors have g, ❑Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers'-comp.•insurance comp. insurance.$
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3. I am a homeowner doing all work officers have exercised their 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_
comp.insurance required]
"Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the subcontractors 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.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to§ecure coverage.as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine 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
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for*insurance coverage verification.
I do hereby certify under the pains andpenal 'es oftperjury that the information provided above is true and correct
Signature: �"t Date.
Phone#:
Official use only. Do not write in this area,to be completed by city or town official O
City or Town: Permit/License# q v
Issuing Authority(circle one): �I
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
f
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their.employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregomgg-engag in a jomt-en ipnse�-mc-.IMn`g.tlie legal-representati�eg�f-
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)andphone 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 permittlicense number which will be'used as a reference number. In addition,an applicant
that must submit multiple permittlicense 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 irrust be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related io any business or commercial venture
(i.e.a dog license of 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,telephone-and fax number:
The Commonwealth of Massachusetts
Department of lndustrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
TO. #617-727-4900 ext-406 or 1-877-MASSAFE
Revised l 1-22-06 Fax#617-727-7749
www.mass.gov/dia
i - -
Town. of Barnstable
zHWE rti
Reg»Iatory Services
Thomas F.Geiler,Director.
MASS.
�,,r �.•� Building Division
Tom Perry,Building Commissioner
_ _ .....___._. .--..___.. ..`....- --.....-. -200 Main-Street,--Hyannis,-MA-026.01 . _:._...._.__.__.... .....-_ _..___....... ......._...........
..:_.
www.town.b arnstable.ma.us
Office: 508-962-403 8 Fax: 508-790-6230
HOMEOWNER LICENSE EXEKMON
Please Print
DATE I o1` IC.- k
JOB LOCATION: 39 w
number street village p
"HOMEOWNER': tZsc`+� �G n(&e r ��� E� o`Z �SS� �S�0 �� �"f OO 7
name home phone# work phone#
CURRENT MAILING ADDRESS: G O X '2 a- J.
c ,y 13s�'a��e , SA--
cityRown 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 be/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.helshe understands the.Town of Barnstable•Building Department
minimum inspection procedures and requirements and that he/she will comply•with said procedures and
requixenients. n
C
Signature of Homeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the
State Building Code Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that "Any homeowner performing work for which a building permit is required shall be exempt from the provisions
of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a pason(s)far hire to do such
work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that they am assuming the responsibilities of a supervisor(see Appendix Q.
Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly
when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed
Supervisor. The homeowner acting as Supervisor is ultimately responsible.
To ensure that the bomeowner is fully aware of his/her responnbilities,many communities require,as part of the permit application,
that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by
several towns. You may care t amend and adopt sucb a fomdcertification.for use in your community.
Q:forms:homccxcmpt
4
r
zTti Town of Barn-stable
. Regulatory Services
,y' `�ss�B Thomas F.Geiler,Director
�'gEn 16 Building Division
Tom Perry,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town-barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and Sign This Section
If Using A B uilde r
as Owner of the subject property
hereby authorize to:act on my behalf,
in all matters relative to work authorized by this building permit application for.
.(Address of Job)
Signature of Owner Date
Print Name
If Property Owner is applying for permit please complete the
Homeowners License Exemption Form on the reverse side.
Q:FO RMS:O WNERPERMISSION
Barnstable Old Kings Highway Historic District Committee
O
200 Main Street, Hyannis,MA 02601, TEL: 508-862-4787 Fax 508-862-4784
KAM
O APPLICATION, CERTIFICATE OF APPROPRIATENESS
Application is hereby made,with four(4)complete sets,for the issuance of a Certificate of Appropriateness under Section 6 of
Chapter 470,Acts and Resolves of Massachusetts, 1973,for proposed work as described below and on plans,drawings,or
photographs accompanying this application for:
Check all categories that apply o
1. Building construction: ❑ New ❑ Addition Alteration
t_
2. Type of Building: ❑ House. ❑ Garage/barn ❑ Shed ❑ Commercial ❑ OthW �Z J
3. Exterior Painting, roof ❑ new roof ❑ color/material change, of trim, siding, window, doors " I
4. Sign : ❑ New Sign ❑ Existing Sign ❑ Repainting Existing Sign 0 m
5. Structure: ❑ Fence ❑ Wall ❑ Flagpole ❑ Retaining wall ❑ tennis court ❑4)ther
6. Pool ❑ swimming ❑ Other man-made pool
Type or Print Legibly: Date: I a o� Address of proposed work: House#
t`l Q cs
Street: to ; I '011j SIT- Village 0L).6rliSf ble Assessors Map Lot# 1}I 01
Description of Proposed Work: Give particulars of work to be donee:l
fry,,6ltIPvs6%� ®a
V� l9 V1n.G t� C� to4?_
Agent or Contractor(print): Telephone#:
Address:
Contractor/Agent'signature:
NOTE All applications must be signed by the cirrent miner
Owner(print): S�cL.,n c �i-16e 1' Telephone 4: �`�� /�' Li O D�.
Owners mailing address: 9 1,3 -S_Ta b l P V'VAA- S�l 4G(6p- _
Owner's signature: -�
For committee use only. This Certificate is he PPROV /DE D
EC� E � �I [
Date Members signatures
DEC t 8- 2008
TOWN OF BARNSTABLE
HISTORIC PRESERVATION y c ditio of approval: !�k'Z''L- 4 �
APPROVED
f .
f�v v �.1/r'u ./t n C' RA ill
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1
C:Oocuments and SettingsldecolliklLocal SettingslTemporaryInternet Fi1eA0LK/10KH CertAppropriatenesT&&-ot Barnstable
Old King's Highway
p E C E Wr
DEC 1 8 200j
o
TO
�. .
WN OF BARNSTZ ' !
Town of Barnstable Old 1[{ing's Highway Regional Historic Distri t((builitrlRESERI/ATi7%!! j
CERTIFICATE OF APPROPRIATENESS SPEC SHEET
Please submit 4 Copies
Foundation Type: (Max. 18 exposed)(material-brick/cement, other)
Siding Type material: Color:
Chimney Material: Color:
Roof Material: (make& style) Color:
Trim material Color:
Roof Pitch: (7/12 minimum) y
Window: (make/model) a jNXQ rSo-✓1 Ll 00 material W r-,y f c--& colorf C`
e.he�
Size(s): Qc-e v� i �0.� S'� �v� S�ch2� Sl'2L , S'ewC�Tri Ertl . 'eG y
Door style and make: material Color:
Garage Door, Style Size Material Color
Shutter Type/Material: Color:
Gutter Type/Material: Color:
Decks: material Size Color:
Skylight,type/make/model/: material Color: Size:
Sign size: Type/Materials: Color:
Fence Type(max 6 )Style material: Color:
Retaining wall: Material: .
Lighting,freestanding on building illuminating sign
Please provide samples of paint colors and manufacturers brochure of style of Windows,doors,garage door,
fences,lamp posts etc
ADDITIONAL INFORMATION:
i
Signed: (plan preparer) print-paw nIIDD�F�ED
tel. no. Location of application e p Q n\/F n
Street illage �`
JAN 14 2009 2
CADocuments and SettingsldecolliklLocal SettingslTemporary Internet FileAOLK110KHCertAppropriateness 07.doc
Town of Barnstable
Old King's Highway
Committee
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BUILDING DEPARTMENT
i s
COMPLAINT/INQUIRY REPORT
Mat . 02 ! 45 R ec'd B v Assess ,
131 -ol
ast Name ,s m + 6m A) First Name
ORIGINATOR Street
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Telephone: Home
Work '790-6'28,5
Description
�tJr % GG'7/2.. G
COMPLAINT G —
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GDkIL SlD w; �[A�k d ,<X4Y �2oalr �'rh
__INQUIRY '
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Requestor's Signature—
COMPLAINT Street Address 3q5 `,�
LOCATION '��ow !3 VE
_OFFICE USE ONLY
INSPECTOR'S Datee A •71 15
ACTION/ Inspector
COMMENTS /-�
FOLLOW-UP ��� �
ACTION
_ADDITIONAL
INFO. ATTACHED
COPY DISTRIBUTION: WHITE - DEPARTMENT FILE
PINK - INSPECTOR (RETURN TO OFFICE MGRN)PECTOR
MIBCl
Application to
129
Old Kings Highway Regional Historic District Committee
in the Town of Barnstable for a
CERTIFICATE OF APPROPRIATENESS
Application is hereby made, id triplicate, for the issuance of a Certificate of Appropriateness under Section 6 of Chapter 470,
Acts and Resolves of Massachusetts, 1973. for proposed work as described below and on plans, drawings or photographs
accompanying this application for:
CHECK CATEGORIES THAT APPLY:
1. Exterior Building Construction: ❑ New Building ❑ Addition ❑ Alteration
Indicate type of building: ❑ House ❑ Garage 0 Commercial ❑ Other
2 Exterior Painting: ❑
3. Signs oir Billboards: ❑ New sign ❑ Existing sign ❑ Repainting existing sign
4. Structure: ❑ Fence ❑ Wall ❑ Flagpole ❑ Other
(Please read other side for explanation and requirements).
TYPE OR PRINT LEGIBLY DATE June 20, 1995
ADDRESS OF PROPOSED WORK 395 Willow St. ASSESSORS MAP7NO. 131
OWNER Susan E. Parker ASSESSORS LOT NO. 17
HOME ADDRESS 395 Willow St. Barnstable Ma_ 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).
130-6 Arthur & Nancy Larincruist 19486 Omega Rd_ Fr Myers Fl. 33917 1
130-7 Robert & Joan Leeman Oar & Line-Rd. Plymouth Ma. 02360
AGENT OR CONTRACTOR NYNEX/Ronald P- ThihndPa„ TEL NO. (SQR) -IQR—S-7Sd
ADDRESS 44 Old Town House Road So. Yarmouth, Ma. 02664
DETAILED DESCRIPTION OF PROPOSED WORK: Give all particulars of work to be done(see No.8,other side),including
materials to be used, if specifications do not accompany plans. In the case of signs,give locations of existing signs and proposed
locations of new signs. (Attach additional sheet,if necessary). n .
11' X 6' X 6' concrete utility vault
Signed
,,,, � Owner-Contractor-Agent
ne for r mi Ronald P. Thibodeau R.O.W. Mahacrer
_- -Received by-H:D.C,_---
rDate irate is hereby ^4 aS kvN or Date s
JUL
_ C �
Time I �� _ 1P Q
Approved ❑ IMPORTANT: If Certificate is approved,approval is subject to the 10 day appeal period
provided in the Act.
Disapproved ❑
4 Town of Barnstable }
Old IGng's Highway Historic District Commission
SPEC SHEET
FOUNDATION CONCRETE
SIDING TYPE CONCRETE COLOR NATURAL
CHIMNEY TYPE COLOR
ROOF MATERIAL COLOR
PITCH
WINDOW SIZE
TRIM COLOR
DOORS COLOR
SHUTTERS
GUTTERS
DECK
GARAGE DOORS COLOR
NOTES: Fill out completely, including measurements and
materials/colors to be used. Three copies of this
form are required for submittal of an application;
along with three copies each of the plot plan,
landscape plan and elevation plans, when
applicable. Plot plan need not be "Certified", '*
but should show all structures on the lot to `
scale.
SPECSHT
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TOWN Of OARNSTAOLE• MASSACHUSETTS'
ASSEBaORB MATS
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/WAKD ON= THE•OIRECnON or THE
' BARNSTAOLE BOARD OF ASSESSORS r • w ••• �1
AVIS AIRMAP INC.. 262
.. rAeSAunlaeTTs aonNcenovr Ae .
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ROTONDO'PRECAST
P.O.;Box 1217 TEL: (203)673-3291
151 Old Farms Road TEL: (800)225-1457
Avon, CT 06001 FAX: (203)675-1294
CEC - 2010 CONCRETE CABINET
Rotondo Precast's Concrete.Cabinet (CEC-2010) offers an ECONOMIC, VERSATILE
and highly SECURE container for-today's advanced electronic equipment The Walk-In
design coupled with the capacity for eight (8) 7' x 23" equipment bays and a completely
CONTROLLED ENVIRONMENT allows for greater flexibility in the use of outside
plant electronics. In addition, it provides a safe enclosed environment for the technician
to work.
CEC-2010 DESIGN ADVANTAGES
• Walk-In design protects technician and the equipment from outside elements.
• Eight(8)7 R x 23 inch equipment bay capacity. .
• Compact design includes the splicing chamber and power-pedestal as part of the cabinet.
No additional on-site cabinets are needed.
• Separate splicing and craft placement
• Full environment controlled interior allows for use of less expensive non-tempered electronic equipment
• No zoning or permitting typically required for placement
• Right-of--way installation.
• Low cost installation.
' _........ Designed.for Copper,Fiber or Radio applications._...__._.... _..
• Four(4)easily accessible 4 inch cable entry ports with cable seal sleeves.
Easily relocatable.
• One(1)2-inch fiber optic cable entry port with cable seal sleeve.
CEC-2010 CONSTRUCTION ADVANTAGES
' Durable long lasting concrete protection: i.e.,falling trees,storms,cars.
' Vandal Proof: Heavy duty steel doors and lochs similar to large Telco
equipment enclosures.
• Waterproof No seams below ground level, walls and floor are one
piece construction.
' Bullet Proof: Solid 4 inch concrete walls.
' Economical: Standard concrete construction offers a lower cost and more
durable alternative to other materials.
• Maintenance Fri: Solid concrete construction with steel rebar reinforcement
• Interior/Exterior Finishes: Available in a variety of aesthetically pleasing finishes that blend
well with the surrounding environment
SPECIFICATIONS:
• Dimensions: Exterior: 6'-0"x 12'-5"x 8'-9 12"(includes exterior mounted equipment).
• Interior. 5'-4"x 10'-4"x 8'-0-
Profile above ground: 6'-0"x 12'-5"x 5'-10"
• Construction: Monolithically poured solid concrete walls and floor(5000 p.s.i.minimum
compressive strength).
Solid concrete roof(removable).
Steel rebar reinforcement
• Weights: 20,732(Without Telco Equipment).
• Installation: 36 inches below grade. No tie-down or anti-float measures are required.
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THE CEC-2000
DESIGNED FOR THE: NEXT GENERATION
NETWORK FROM: THE- BLUEPRINT UP
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"� . The Town of Barnstable
MASS, ' Department of Health Safety and Environmental Services
1639. p�0� Building Division
Eo N,pr
367 Main Street,Hyannis MA 02601
Office: 508-862-4038 Ralph Crossen
Fax: 508-790-6230 Building Commissioner
TOWN OF BARNSTABLE P
SOLID FUEL STOVE PERMIT Date::
Fee:t` dv
Z.
Owner: ;5 Lls c v` QPG�1&_i2 Phone:
Address:8 ls_ LA)" ��� S� Village:
Map/Parcel: Date: o v
Stove
A. Ne /Use
B. Type: Radi /Circulating
C. Manufacturer: O c.�W-e _ Lab. No.
D. Model No.: Q A NS i v L 8a a 6-9
Chimney
A. New �'stin (If existing,please note date of last-cleaning): -- -
B. Flue Size X/
C. Are other appliances attached to Flue? 0
D. Pre-fab Type and acturer
E. Masonry: Line nlined
Hearth f
A. Materials: rlC
B. Sub Floor Construction: CovkCM
Installer II
Name: . CG /h d u h Address: 3.3 Wetnopnoeq
Phone: 509 9gg N 0 7 P/yVV1 0
Location of Installation: -i-
AP
PROVED BY: �
Please make checks payable to the Town of Barnstable
*This constitutes an official stove permit after inspection,photographed, and approved by the
Building Inspector
Stove.doc
y
�'
0 2 0-3 4 0 1 90-3 4 - :F'�l'i Rf7i_CrC 36 .
,Y
Assessor's Office j 1st floor Ma Lot 4/7 r0
Permit#
;i Conservation Office 4th floor ,J -��.� %` . 1
®`� Date Issued
Board of Health Ord floor a
k Engineering Dept. Ord floor House# �S �����
Planning 1 Dept. 1st floor/School Admin. Bld . : a wwWASM t
Definitive Plan A roved by Planning Board
19
A lications ssed 8:30-9:30 a:m:&.1:00=2:00 .m. ®® •����p �u
TOWN OF BARNSTABLE
Building Permit Application
Project Str J ('T ;t—j( cam/ -�
Village Q— Fire District
i Owner S'c�ea.� /�G�-c.(Ct✓v�_ Address
Telephone
Permit Rcc ucst: S'r C�e
zT --
Zoning District Flood Plain Water Protection
Lot Size Grandfathered
Zoning Board oLAppeals Authorization Recorded
Current Usc Prop2sed Use
Construction Type
E:istine Information
Dwelling 7'vpe: Single Family Two family Multi family _
Age of structure S:-D Basement type
Historic House Finished
Old Kin-,'s Hi hwa Unfinished
Number of Baths f No of Bedrooms /
Total Room Count(not including baths) First Floor L�
Heat Tvpe and Fuel Central Air Fireplaces4_7
Garage: Detached Other Detached Structures: Pool
Attached ------- Barn
None Sheds
Other
Builder Information
Name L-r -66+ I �e n— Tele hone number
Address Li #-
Home Improvement Contractor#
Worker's Compensation # t
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
Pro'ect Cos OZ�
Fw
SIGNATURE �I � DATE �'J I t `►u�
BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S)
SPERM T
i
5/15/95 37755
131.017
395 Willow Street., W. -Barnstable
i
Owner: Susan E. Parker
TOWN OF BARNSTABLE
BUILDING DEPARTMENT `
---------------HOMEOWNER LICENSE EXEMPTION
Please print.
DATE
JOB_ LOCATION
of town
"HOMEOWNER" SC"S Pll I�t_ 3 $—
S
Name Home phone Work phone
PRESENT MAILING ADDRESS----------------
City/town
State Zip cod
The currp"+ 15'1= , 4 „
-------L -_on for homeowners" was extended to include owner-occup.
dwellings of six units or less and to allow such homeowners to engage an is
dividual for hire who does not possess a license, provided that the owner
acts as supervisor.
DEFINITION OF HOMEOWNER.,
Person(sj who owns a parcel of land on which he/she resides or 1.intends to
side, on which there is, or is intended to be,- a one to six family .dwellinc
attached or detached structures accessory to such use and/or farm structure
A person who constructs more than one home in a two-year period shall not l
considered a homeowner. Such "homeowner". shall submit to the Building Off-'
on a form acceptable to the Building Official, that he/she shall be respon:
for all such work performed under the buildi-- ermit. (Section 109. 1.1)
The undersigned "homeowner" assumes responsibility for compliance with the
Building Code •and other applicable codes, by-laws, rules and regulations.
The undersigned "homeowner" certifies that he/she understands the Town of
Barnstable Building Depart-ment minimum inspection procedures and reauiremer
and that he/she will comply with said procedures and requirements. +
HOMEOWNER'S SIGNATURE
APPBOVP_T• OF BUILDING OFFICIAL
Note: Three family dwellings 35 , 000 cubic feet, or larger, will be require;
to comply with State Building Code Section 127. 0, Construction Control.
I
t.•3'"� yE .��,f�� — 1, }: i`Z'l $t )♦j r yr' y .`)1 .`J�`=r a '1 .�� .
The Town ofYYf BBarnstable
MPMAMM
KASS
tee$ Department of Health Safety and Environmental Services
+ ' BuiIding Division
367 Main Street,Hyannis MA 02601
Office: 508-790-6227 Ralph Cr ossen
Date
AFFWAVIT
HOME U"ROVEMENTCONTRACrORLAW
SUPPLEMENT TO PERKMAPPUCATION
MGL c 142A requires that the"reconstruction,alterations,renovation,rcpait;modernization,conversion,
improvement, remo%al, demolition, or construction of an addition to any poe4odsting owner ooa:pied
building containing at least one but not mono than four dwelling units or*to which are adjacent
to such residence or building be done by registered contractors,with oataia exceptions,along with other
r' -
Type of Work Sh�h_'1 l i °1 Est Cost 43 60
Address of Work: Yc6 �'`� i � ' d ✓ -Y` '
Owner Name:
Date of Permit Application:
I herein•certify that:
Registration is not required for the following reason(s):
Work exciuded by law
-,--Job tmderS1,000
Building not owzur-occupied
Otxna pulling own permit
\`c:;=is hcrcb}•givcn
OWNTERS PULLING THEIR OWN PERMIT OR DEALING WIITI UNREGISTERED CONTRACTORS
FOR APPLICAELE HO\ E RIPROVENIE'N7 WORK DO NOT HAVE ACCESS TO THE
��E:irr 4.TION F:.CC ._'„ OR GUARANrn'FU: LTNDER?•;GL c. 142.A
SIGNED UNDER PENALTIES OF PERJURY
I hcrcbN,apply for a pewit as the agent of the owner:
Date Contractor name Registration No.
OR
Datc Ouster's name
11:02'94 17:02 'C6177277122 DEPT IT'D ACCID k
T = l�0/iZIYlO/1dUP.LZLt�L Ot I/11/Qijachwietb
�UaPartntent o�J'•na!u�friaL.�1cGcdan[1 .
600 Wal gton..S'tm+ t
James J.Campbell &ton, //(amacLu 02f f t
Commissioner .
Workers' Compensation -Insurance davit
(aoatsee�pamiaee)
with a principal place of business at: -
do hereby certify under the pains and penalties of perjury, that:
() I am an employer providing workers' compensation coverage for my employees working c
this job.
Insurance Company PoCey Number
() I am a sole proprietor and have no one working for me in any capacity.
() I am a sole proprietor, general contractor r homed (circle o:ze) and have hired the
contractors listed below who have the folio rkers' compensation policies:
•.er".,` S�As:Ti✓
Contractor Insurance Comparry/Policy Number
Contractor Insurance Company/Policy -Number
Contractor insurance Company/Policy Number
() I am a homeowner performing all the work myself.
1 u,1cersU x-h-tt::cc;;-/of&.s s_tement will be fo e zrced tc&-e O`5ce of invem,7.—bons of the D1A for cowrage verifies.ion and that fzaure to
5,1
ccvrage:s ree:i.ed tinder Sec-on 25A of MGL 152 c:n lead to&,c Imposition of criminal penalties eonsisdn¢of a fine of up to S 1,500.00 arcf'
years' imprsc.nment.-%s wen as civil penalties in the forr..cf a STOP WORK ORDER and 2 fine of S 100.00 a day against r-..c.
Signed this 5 day of
19
-- %A-1-11
Ucensee/Permittee Building Department
Licensing Board
Selectmens Office
Health Department 577S--s—
TO VERIFY CCVEP.�Gc INFOkMF,TION CALL: 61 7-727-4900 X403, 404, 405, 409, 375