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1610 MAIN ST./RTE 6A(W.BARN.)
UPC 12543 No 53LOR HASTINGS,UN TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION + ;�picaPon )#Map Parcel Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH` _ Preservation/ Hyannis Project Street Address 0 6,vb-e 6 A Village Owner L. i S KJ e Address I(. 10 Telephone, 17 6 SO -- 4; 7 Q 1 a Permit Request , e Lax, 7 i. �s Vs s c e<< r. l Par. rl.T Square feet: 1 st floor:existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project-.Valuate 0 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Ca"" Two Family ❑ Multi-Family (# units) --_1 — C � Age of Existing Structure Historic House: El Yes ❑ No On Old King's Highway: aes 0 No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other f ry Basement Finished Area (sq.ft.) Basement Unfinished Area (q.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 ❑ 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 T-3��1 ��-d G-tee.. Telephone Number J—yfr-7 3.S- 9 f G 0 Ix Address 7 Y 0..,j •(I IIJ ' License # C S O 7 i 3 01 .7 14o(��..df, A o rS"a ► Home Improvement Contractor# 10k`/70 A Email (G Cr 1 Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE .S-�9I/q I FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED . 1. MAP/PARCEL NO. Y ? ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION 1 , FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL v FINAL BUILDING Aa DATE CLOSED OUT ASSOCIATION PLAN NO.: *s-,r ,. APPLICANT INFORMATION (BUILDER OR HOMEOWNER) N,1d e r :"!jA s, �s �_ Telephone Number S ds �(�'�'I'L•o-o O dress o�(o !► �cA�� �'�� License# CS 041 96� - f— d i.SG� Home Improvement Contractor# ChB 4`7 0 Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE 7 /1 ''C Die Commoyntwa ik ofMassachuseffs Deparhmmt of li drrstr.id Accidents - - Duce of�rz�estigo�iorrs s 600 Washington,meet Boston,.MA 02M wn'w rriasmg&Vdi a 'tea:rkers' CompensationInsurance Affidavit.Builders/Contractors/E.ectncians/Plumbers AppEcant Information Please Print Legibly Name(Susinesdorganization/t>fividnal)_ �,,� �o�-•-S Address: City/Stabt-Jzip_ �o e� M� otS Phone �G fs' (?6 7 Lf"It C a Are you an employer?Check the apprapriate bow Type of project s 4. I area. contiactar and I l (required):. I.El I am a employer with 6- ❑New construction eru>ployees(full andlorpart-time)* have the sub-conlradors. 2 am a sole proprietor or partner- listed on the attached sheet 7- ❑Remodeling ship and have no employees Th sub-contractors 'e 8- Demolition w for mein an c ci employees and have workers' I ° Y � t3- c ���$ 4_ �]Building addition. WO Workers' comp_kw1rance comp- required] 5_❑ Vile area corporation and its 1.0.1--1 Electrical repairs or addhioas 3.❑ I am a homeowner doing all work officers baum exercised their 1.I-(]Phruibing repairs or ad&tioLns t. f fion er MGL myself [No workers'comp- � o Pik p ].?.n Roof repa>rs insurance regnired.]T c. 152, §1(4} and wefiaveno employees-[No workers' 13_❑O.d r comp-insurance requiie .J- *Any saptimmt tbat checks boa ml mist also fill our the sectian below showiie their woffCen'compensation policy inf wmEc n_ T Hnmeawners vrho submit dis afadsvA ind catmg they an doing nH troalc and then hive outade contrwMrs most submit a»:.ffidavA ma;_—rs such t0mitmctors thst check this box must sttached an additions)sheet&hawing the name of the sob-routs and state xhether octant those hsva Employees- Ifthe sib-contmdorshave empIoyees,t$eymust provide their workers'comp.policy ntrnbes I am an errrplayer ihrrt`2s prm�idterg tt�orkers'eartrparuralio.n irururartce for trr}r errrpin}%ees. .t3eTots is Ste po8cp artd job stt� informatiam Insurance CompanyName: Policy#or Self im Lic-;k 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 mquirednuder Section 25A o€MUL c 152 can lead to the imposition of criminal penalties of a fine up to$1,50D_OO and/or one-yearimprist»t,as well as chat penalfies in the form of a STOP WORK ORDIRand a fine of up to S250.00 a.day against the violator_ Be advised that a copy of this statement may be forwarded to the Office.of Im-estigations of the DIA for insurance coverage verification_ I dd hereby certify it. s pmns andpena Was of penury ScatSte iruforrrsation prcn ide-d above cr.hus and correct Sia�aature_ Bate: 1 `t Phone 9: "-7 ` ©flout use anly. Do—not write in this area,to be completed by city or town of iciaL City or Town: PernritUcense# Ias-uing Anthority(circle one): 1.Board of Health 2.Building Department I Ci.tF-!I awn Clerk 4.EIectrical Inspector 5.Plumbing Inspector .6.Other Contact Person. Phone!#_ 6 Information and Instructions , Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuantto this statute, an en ployee is defined as".-.every person in the service of another under any contract of hire, express or implied, oral or written." An employer is demmed 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." i MGL chapter 152, §25C(6)also states that"every state or Iocal licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct bnildings 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 perbormance of public work until acceptable evidence of compliance wi'u 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 nuTmber(s)along with their cer lscaie(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(T LP)with no employees other than t-be 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 Indusaial Accidents for confirmation of in urance coverage. Also be sure to sign and date the at 5davit 11he afi?dat6t sboul_d be returned to the city or town that the application for the permit or license is being reclutsted, not the Department of Industrial Accidents. Should you have any questions regarding the law o 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 EM in the permitllicease number which will be used as a reference number. In addition,an.applicant that must submit multiple permit/hmnse applications in any given year,need only submif one affidavit indicating current policy information (if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the 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 (Le.a dog license or permit to bum leaves etc.)said person is NOT required to complete this aihda,,-it- The Office of Investigations would lice 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 Degartrnent of Industrial Accidents Office Of kvesdpfians 6600 Washingtau Street B aston.IAA 02111 Tel.#617-727-49-GO W 406 or 1-977-'_viASSAFE Revised 4-24-07 Fax# 6I7-727-TI49 www.mas,&gav1dia f _ } MASS. Town of Barnstable Regulatory Services Richard V.Scali,Director Building Division Thomas Perry,CBO Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder L b5a e- as Owner of the subject property 1 by c. �;rC�T►�'� hereby authorize way to act on my behalf, in all matters relative to work authorized by this building petrnit application for: (Address of Job) lb 111)�1,9 ICI S atute • f caner Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the reverse side. Q:\WHILESTORMS\building permit forms\EXPRESS.doc Revised 061313 Town of Barnstable Regulatory Services oFq rOy,� Richard V.Scali,Director a Building Division f SSTT"LF Tom Perry,Building Commissioner MASS. 1639• ��� 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us - Office: 508-862-403 8 Fax: 508-790-623 0 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to be, a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. s Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127:0 Construction Control: - HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems, particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities, many communities require,as part of the permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 0 613 13 Colonial f i Restorations Post&Ream` Bwdfiny Stmig coned I Raven tion andl-W Sills R?Iaced Consuhations www.cr198l.com Tom Gmen 867-7698 Hon ` BradG� sob e 867 4400 O�iu ^-s�.r a M i v v 84 OX) cY� ✓ _ 00 [V�; LJ ILA V 0 ° BMassachusetts Department of Public Safety oard of Building Regulations and Standards ' Construction-Supervisor License: CS-042865 •? { Thomas O Green 26 Main Street#5 . Brookfield MA 0F506lug Expiration Commissioner. ".> M./31/2016 A +tihaaMh ta�k,� ,� •,(rT '�hSE"^ � Ft. � irj �tkyl erntgs y[a t+ r r y�{����yggq,,,,d 3t; �;n i a.�_'�:.'i'y*W,�y�y.��Y(r(f�.�'�J<<�r ,�S � -'p, • _ , 0, ��UVI AJ rr��,, {{�� a �'".F-K�V•�r'�,X-.t4fi�"lr>�4JP1 it'.'��C. tw �14 , �s ( � rv�" ;."pF'eS`*1{� , � ,('°���. �}al7.y� aI� ��.. I.++h� �R'Fv,'2�: W '1`!'i4*�IU• 'qJh". �' { iI 1 C N � F (����•,-,lS',,, y,.�+ t- .V• " £� ttrr ""�pye rr, y ���'{r't r,,:}xrk.T..`v sF^1 a C Alp." A;W' a.�i�.� F" - nS S� +Yr �'�$/�'� 'y'�^�(/e��•^ ?' �' L _Y�'�; tF,..,Y t �. s' _ � . l't•�"']CTI /y�C�j �` -�.1 �1,Lr3��� V <�V� t:�l# + }i. T i+l,'�{y�ry„t�4 Y ���� t �'• f t Y IrF, k 1�Vl, �• i` 4fn`7'1 iV• T ` tMri� '{ d •��, t-'+�?�,1Ri �,r�`�#��s'�' .�'��?�S..t�f, t•�- �u�w'��z�'f ,r'� }t s� i.e t�'x�+ ,;. • ,�'xF + �tti, �.aftE�ro,�� ,+t r„^ 51 }Y{ �``� �"dh.��•`�t t"��„�•�' n �14�,ti'�x i xir• ; °;� .r""ppr�� y`�t�.'' �+t��. �' ,.a! ,� .,,� �F m.51 � .o- r �r t•y��fh, }'k+� � �""N. - .d"Y G (� ,�'cQ^' ` �4��? ��5. s Ow M-NI � .:F.- c;4AR ' rk%X'VI �`°4 .k �: y�e4t $ r ! ,� + fir } �t. s� 1 r 4+ Bcoofieltl,aN�lAr�d1' 03� r 4r i `�, '..s +51""4'"�"-.�-k 'lit,1 '',j y�"�'4},''r. ]�`r'u Y� i?l N'.•�� +'s t'sW `t;R..dot� NO 4RM",4w �,( �3 t., {k.� +N"l � �Yrv'�t��� �a`�•4R IY A;S 1 �EF�LN �i yC'�rwtR�`y�41,t'�`h'•z3r'yy�y,�7�. .' , c '�y y k y s � 3 f � � r ,PM" ,+„ »ltiL,u e'!a' `8x #'r '"' b '�"e d -F ,�i ++� �,.x•'gai'`i , .�t� n-t Aw s License or registration valid for individul yst onA. before the expiration date, if found return to: Office of Consumer Affairs and Business Regulation •10 Park Plaza -:Suite 5170 , Boston, MA 0211b 1 S • ,' ".'-*' �'velo4without signature � �:1� 'Y �� •�i .��+- Fit. 1 f v. +�ii�j - ' � 'p: -,'. �• - K.'%''iE fry �:: . 1 e.'rn �.y' ♦�J It ^ r1 a•x��v/�ry f�i.��� zao( ®p PERMIT . Town of Barnstable *Permit# Expires 6 m date Regulatory Services Fee z .2012 � MASS. Thomas F.Geiler,Director ArEt)MP't a ' TOW . BARNSTABLE Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barmtable.ma:us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/paroel Number Property.Address 6 � residential Value of WorkV Ot< -c� Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name Telephone Number So 9' Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor Q'I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) A11 construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side 5�� P 0� n' �n b #of doors E21ieplaceiiient Windows/doors/sliders.U-Value (maximum.35)#of windows ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and.inspections required. Separate Electrical&Fire Permits required. - i *Where required: Issuance of this permit does not exempt compliance with other town department.regulations,i.e.Historic,.Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: n•\vjPTm.Fs\FORMS\buildine permit forms\E)PRESS.doe I 1 � The Commonwealth of Massachusetts -tip►\ Deparonmt of Industrial Accidents O,fce of Investigations 600 Washington Street Boston, 4-02111 . www.masmsgov/dia Workers' Compensation pensaon Insurance Affidavit.. Builders/Contractors/Electric ans/Pbunbers. Applicant Information I �//�� ] Please Print Legibly- Name(Busine�Organizationllndividuai): i94eit /T0f0 ,41 nG L i' Address: b /C1 City/State/Zip= &y•&/t,tiscj/9 Phone,4*k oS Are you an employer?Check the appropriate box: Type of project(required): 1_❑ I am a employer with 4. ❑ I am a general contractor and I employees{full an(/or part-#imie). # have hired the sub-contracboas 6- ❑New comsfroCtion 2.❑ I am a sole proprietoi or partnr- listed ore the attached sheet: 7- ❑Remodeling strip and have no employees Theme -contractors have g. ❑Demolition w for me employees and have wodcers' working any capacity- 9. ❑Building addition U workers'comp.insurancecomp.mmxarxp Z required-] 5. ❑ We are a corporation and its 1a•❑Electrical repairs or additions 3..[�(I am a homeowner doing all work officers have exercised dwir 11,[]Plumbing repairs or additions right of exemption per NIGL myself (No workers'comp. 12.❑Roof repairs insurance r c. 152,§1(4),and we have no d�T employees-toam- ❑ [No workers' 13. Other�7Pl�-CCfa"1CyGh comp.insurance required:]: *Any applicant that chedu boa#1 mast also fill mat the section below showing their workers'compensation policy information 1 Homeowners wbo submit this affAw t indicating they are doing all wed and then hue outside contra dmrs.om 'submit anew affidavit indicating such +'Contmcmrs that check this boar must attached an additional sheet showing the name of the sirb-c®daactors and state whether or not those entities have employees. If the sub-contizcsaa have employees,they mustprovide their Niwkers'comp.policy number. lam an employer that b providing workm'compsrtradon insurance far my omployees. Below is the poiicy and job site. information Insiumce Compazsy Name: Policy#or.Sseif ins.uc.#: Expintian Date: Job Site Address: City/Statelzig: Attach a copy of the workers'compensation policy declaration page(shoving the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. LS?'can lead to the imposition of criminal penalties of a fine up to S 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 cotiwage v_er�icn-. I.�hereby certiunder theP ns and nalties afperjury thatthe information provided above is..Grus and correct Phone#: 0, use only. Do not write fn this arad,to be completed by dty or tem.1 officiai City or Town: Permit/License# Iss ing "thority(circle one): I..Board.of Health 3.Buffing Department 3.City/Town Clerk &Electrical Fnspector 6:Plumbing Inspector 6.Other i t; °4,1rgy� Town of Barnstable Regulatory Services ' aattivASS MASS F. Geiler,Director � g' - Fo;g.t Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis, MA 02601 www.to.wn.barnstable.m.a.us. Office:. 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: f U 1 Z6- Zo/-,7 JOB LOCATION: C!G /t'�4(✓U�jL �� numbler,, 11 street village "HOMEOWNER": Pt°�-e2 �67L,4, lam(L Sra>s 36y- 33�-5� name �7home phone# work phone# CURRENT MAILING ADDRESS: 1�0 bG T Alt. - ,44- 0 Z6-7Z 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 proc dures and.requirements and that he/she will comply with said procedures.and requirements. . Signature of Homeow er 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-0c.a - of IKE rgrf. cam.•. amwsrnBL 9� HASS.. ,�� Town of Barnstable ArFD MA'S A Regulatory Services Thomas F. Geiler,Director Building Division Thomas Perry, CBO. Building Commissioner 200 Main Street,' Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder 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) . i Signature of Owner Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on,the reverse side. O:\WPFiLFS\FORMS\huildina nermit fnrmS\RXPRRSS dnr. . 00HWE av Town of Barnstable *Pert# 'l• Erpires 6 monthsfrom issue date Regulatory Services Fee ,�5, 7eo) s + IARNSUBLE, v MASS. Thomas F. Geiler,Director 1639. �lED MP't A Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bams table.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Yalid without Red X-Press Imprint Map/parcel Number Property Address , �® TZ* LA w ' `i�"`s�b�" Rl residential Value of Work $ 7 C?('y Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address i La to iA IN i�av w6 � Contractor's Name &V us &AbY 6 4R t a" I i2_Y Telephone.Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) � 'ya ❑Workman's Compensation Insurance ��®��� �EIRIT Chec ,6ne: MESS a sole proprietor ❑ I am the Homeowner APR -.6 2010 ❑ I have Worker's Compensation Insurance TOWN OF BARNSTABLE 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 lay�er®s of roof) C ' �e-sidevbV e_ WO #of doors replacement Windows/doors/sliders. U-Value 3 D (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 required. SIGNATURE: - ----------- -- QW,TFILESTORMS\building permit fonns\EXPRESS.doc ��. The Commonwealth of Massachusetts Department of Industrial Accidents Lr Office oflnvestigations d 00 Washington Street Boston, MA 02111 wivmmass.gov/din Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): Z)tA i! LY Address: Zti`i �— City/State/Zip: ocug 0,W Phone M S©�' ©�°o`f Are you an employer? Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with 4. Ej I am a general contractor and I ployees (full and/or part-time).* have hired the sub-contractors/rK 6. ❑ New.consirtaction 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 mein any capacity. employees and have workers' Building addition [No workers' comp. insurance comp.insurance.) required.] 5. Fj We are a corporation and its 10.❑ Electrical repairs or addition 3.❑ I am a homeowner doing all work officers have exercised their I LE]Plumbing repairs or addition myself. [No workers' comp, right of exemption per MGL 12.E] Roof repairs insurance required.] t c. 152, §1(4),and we have no employees. [No workers' 13.[;'�ther WSt�. 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. tContradlors 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 and job site information. Insurance Company Name: Policy# or Self-ins. Lic.M 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 STOP WORK ORDER and a fins 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 ins and penalties ofperjury that the information provided above is true and correct. Signature: ri1el� Date: Phone#: —TOY— 2se) —404 a Official itse only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License# Issuing Authority.(circle one): 1.Board 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,constriction 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), addresses)and phone number(s)algng with their certificate(s) of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(UP)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 pen-nit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact.you regarding the applicant. Please be sure to fill in the permit/license number which will.be used as a.reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i,e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial.Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASS.AFE Fax # 617-727-7749 Revised 4-24-07 www.mass.gov/dia ;z �YHF T� Town of Barnstable Regulatory Services 9� LF, Thomas F. Geiler,Director Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder T 1 7e, 4h.ttzw as Owner of the subject property hereby authorize J iet,v ko (,w-aY to act on mybebalf, —n all matters relativeto work authorized by this building permit application fox: (Address of Job) P �= Signa of Owner Date Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the-reverse side. Town of Barnstable F'IHE)p� T Regulatory Services • ' Thomas F. Geiler,Director BnaNsrABLE. "`"SS. Building Division' plf10) Torn Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.b arnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: village number street "HOMEOWNER": work hone# name home phone# p CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a•license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such homeowner shall submit to the Building official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner -Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be.required to comply with the State Building Code Section 121.0 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 tS a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often.resu]ts 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. nor. Off-,W16f HOME.IMPROVEMENT CONTRA License dr re istrat CTOR g ion valid for individul use only Registration� `114561 before the expiration date. if found return to: Expirafion:�,1,014/2011 Office of Consumer Affairs and Business Regulation Type, p.B._ Tr# 288716 ' 10 Park Plaza-Suite 5170 �1 DAVID GAD _. Boston,MA.02116 Y•CARPENTRY= David Gady _ 217A.Timber.Ln --' Marstons Mills, MA�p2�48' -� Undersecretary Not valid withou signature Massachusetts- De rt .Board of Building 1�Mmcnt of Public Satet� Rea Of ndards ons and Sta Con cti struon,Supervisor License License: Cs 57546 Restricted to: 1 G _ DAVID J `GADY 217 A TIMBER LN' _ ( J MARSTONS MILLS; MA02648 Expiration: 12/28/2011 C'ommissioncr' Tr#: 14061 A , °Ft r Town of Barnstable *Permit,"Yo�6� 'l Expires 6'ntontft am issue date Regulatory Services Fee _. IARNSrABLE, : Thomas F. Geiler,Director v MASS. 1639• ��� / Building Division %7 �f �prED MA't a Tom Perry, CBO, Building Commissioner e 200 Main Street,Hyannis,MA 02601 www:town.bams tab l e.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 1,, '^ � Property Address !t' � D Uv l a`A St- 1 +Residential Value of Work qI Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address C= t Z C%, b,�_ Contractor's Name Yh� ���U` `''►�� • Telephone Number— Home �� (° 2 —('q V 2 Home Improvement Contractor License# (if applicable) � 13 ❑Workman's Compensation Insurance -PRESS PERMIT Check one: AUG 2 6 ZOQ8 ❑ I am a sole proprietor ❑ I am the Homeowner TOWN �F �A���TAB�.� I have Worker's Compensation Insurance Insurance Company Name /V w 46-Owl VO `,a S` y' 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) SCE-M-Z ip6, - ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (maximum..44) *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: 0V1_1t L , Q:\WPF[LES\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 PleasIA e Print Legibly Name(Bus►ncss/organinfion/lndividual): I�D M 2 J� 6� l' 1`.oV�12 S , S —Z�n c Address: CLtylStatP./Zlp: )o j k G a 3 33q Phone-#: Ov - S" `7- S� 1&a Are you an employer? Check th` appropriate box: r7. E] f project(required): 1.ICI am a employer with U 4. I am a general contractor and I New construction employees(full and/or part-time).* have hired the s'ob-contractors 2-❑ I am a-sole proprietor or partner- listad on the attached sheet Remodeling ship and have no employees These sub-contractors have g, Demolition working for me in any capacity. employees and have workers' 9 Building addition [No workers' comp.-mstnance comp.insuranCe.t rtg�t�] 5. We an a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their l l.[]Plumbing repairs or additions myself: [No workers' comp. rigbt of exemption per MGL 12 CA,�toof repairs insurance required.]t c. 152, §1(4), and we have no employees. [No workers' 13.❑Other rs comp,insurance required.] *Any applicant that checks box#1 must also M out the section below showing their work='compensation policy infmfTmfien- t Horntovenus who subffit this affidavit indicating they are doing all work and then him outside eont actors oust submit anew aff &zvit indicating such. tcontractors that check this box must attached m additional sheet showing the name of the sub-=ftacton and sate whether or not those entities have cnployees. If the sub-contractors have employees,they must provide their workcas'camp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. An Insurance Company Name' uV C Policy#or Sclf-ins.Lie.#: S Expiration Date. ( 09 Job Site Address: l IO /D ' ^� S City/Statdzip: id, F Gc4-A34,tJpla 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 civr7 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 maybe forwarded to the Office of Investigations of the D14 for inemance coverage verification.. I do hereby certify under the pains-and penalties of perjury that the information provided above is true and correct c/ Si e: �^�t( �_ Date: 2 �d Phone# J� �i ` -1 2- 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/Towu Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person• Phone#: I °FVE►° Town of Barnstable Regulatory Services BAxNSTeBLe.�' Thomas F.Geiler,Director rEntin�A Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder C,' P 1 I I�r a Owner of the subject property Y s 0 J p p tY JJ h�,e hereby authorize '�� i�c Zto act on my behalf, in all.matters relative to work authorized by this building permit application for: 1 V Ze A••A ggf"Vl (Address of Job) Signature of Owner li-Je Print Name If Property Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Town of Barnstable �OF1HE T�ti Regulatory Services Thomas F.Geiler,Director BARNSTABM MARS. ��{, ►bs9. ,�� Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis, MA 02601 w".town.barnstable.ma.us Office:. 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: IOB LOCATION: number street village "HOMEOWNER': name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and, to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINTTION 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. Th'e undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be.required to comply with the State Building Code Section 127.0_Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homcownerrs 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. 1 A ®f?�rM CERTIFICA E OF LIA131LITY INSURANCE 02/26/08YYYY) PRODUCER 1-404-995-3000 THIS CERTiFjCATE IS ISSUED AS A MATTER OF INFORMATION Marsh USA, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR homedepot.certrequest@marsh.com ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 3475 Piedmont Rd NE, Suite 1200 Atlanta; GA 30305 Fax (212) 948-0902 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA:Steadfast Ins Co 26387 Home Depot U.S.A., Inc. The Home Depot, Inc. INSURERB:Zurich American Ins Co 16535 2455 Paces Ferry Road — Building C-8 INSURER C:Illinois Natl Ins Co 23817 Atlanta, GA 30339 INSURER D:American Home Assur Co 19380 INSURERE:New Hampshire Ins Co 23841 COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDI — POLICY EFFECTIVE POLICY EXPIRATION L R INSRC TYPE OF INS RANCE POLICYNUMBER DATE MM/DD Y DATE MM/DDIYY LIMITS. A GENERAL LIABILITY IPR 3757 608-02 03/01/08 03/01/09 EACH OCCURRENCE $4,000,000 X COMMERCIAL GENERAL LIABILITY LIMITS OF POLICY ARE EXCESS PREMISE I KL:NI rence $1,000,000 CLAIMS MADE aOCCUR "OF SIR: $1,000,000 PER CC" MEO EXP(Any one person) $EXCLUDED PERSONAL BADVINJURY $4,000,000 GENERALAGGREGATE $4,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG $4,000,000 X POLICY PRO- JECT LOC B AUTOMOBILE LIABILITY HAP 2938863-05 03/01/08 03/01/09 X COMBINED SINGLE LIMIT $1,000,000 ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY. $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) X SELF INSURED AUTO PROPERTY DAMAGE $ PHYSICAL DAMAGE (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO - OTHER THAN EA ACC $ AUTO ONLY: AGG $ A EXCESS/UMBRELLA LIABILITY IPR 3757 608-02 03/01/08 03/01/09 EACH OCCURRENCE $5,000,000 X OCCUR CLAIMS MADE AGGREGATE $5,000,000 DEDUCTIBLE S RETENTION $ $ C WORKERS COMPENSATION AND 1928757 (FL) 03/01/08 03/01/09 X T RYTA IT F .D EMPLOYERS'LIABILITY 1928756 (CA) ANY PROPRIETORIPARTNER/EXECUTIVE 03/01/08 03/01/09 E.L.EACH ACCIDENT $1,000,000 E OFFICERIMEMBEREXCLUDED? 1928755(AOS) 03/01/08 03/01/09 E.L.DISEASE-EA EMPLOYEE $1,000,000 If yes,describe under _. SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 OTHER F TX Employers Excess TNS-C45197967 (TX) 03/01/08 03/01/09 Occurrence/SIR 25M/2M D Workers Compensation 1928759 (QSI) 03/01/08 03/01/09 E Workers Compensation 1928758 (KY, MO, NY, WI) 03/01/08 03/01/09 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS *FOR EVIDENCE ONLY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION THE HOME DEPOT, INC. DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL 2455 PACES FERRY RD., N.W. BUILDING C-8 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. ATLANTA, GA 3Q339 AUTHORIZED REPRESENTATIVE USA *417 ACORD 25(2001/08)datkinson ©ACORD CORPORATION 1988 8213215 C� l\ Ll .-+ a_ cc J O C- �e L^as+ra�raxiyxt`lJd.a�✓�zataa�uce�2 �-\ Board of Building Regulatlons and Standards T License or registration valid for indlvidui use only _ _ HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: LO Registr8,tigq;, 128Sgg Board of Building Regulations and Standards Jr) Expiration;=.WM0 30 One Ashburton Place Rm 1301 ;TRe: supplement Card Boston,Ma.02108 The Home Depo€ At-Horne'Selviice FAARK NIADA 3200 COB$GAILERlk0KW.Y..Y20 XTLANTA,GA 30339• - Administrator ot vat idwithou signature S J QQ W LJ W J L.L —i J W 3 d- 1 Lrl. l J UJ • J ¢ 08-26-2008 13:35 FROM-THD AT HOME SERVICES +508 756 8823 T-084 P-002/004 F-495 nvivia"abet'!V r_tvie,tN,t wtN I xnL;1 PLEASY READ THIS Sold,Famished and]-stalled by: zranchNamc:•Boston Date: 3-/Zq-aL TKD At-Homo Services,Inc. . . : . d/b/a The Home Depot At-Home Services Branch Number. 345A(Irccuwood Street,Unit 2,Worcester,MA 01607 ❑North 3$ ' south 31 Toll Free(800)657-5182: Fax(508)756.88M Pedetal ID#7s369946t,ME Lio#C 02439;RI Cont.Lie#16427 CT.tic#563922;MA H011101ntprw�oMont Coatmctor RCS.#126893 lnstallAdon Address: gxL iA S 1' `� Q�S Ld'� �L7/� �.�(ZJ0 city- State zip PnrcLoeer(e):• workrhonc: Home Phone. Cctlphane: woe Home Ad&vgs: i- (if difFerent from,Installa i=Address) City State Zip E=maD Address(to receive project cormnunicatioos-andWome'Depot updates): El 1 DO NOT wish to receive any!nuActing crnaiis-t rn'ne Horne Depot Pmiect nfnrinaNnn: Undersigned("Customer•)',the'owners of the propany located at tbo above insta latio-'address,agrees to buy, and TkLD At-Homo Services,f-c.("The Homo Depot")-grow to furilil deliver-and arraige for the installation("Tastallation-)of Alt materials described oa•tbe-below and.on the•rofomacod•Spec.Shect(s), all of which arc-incorporatod.into:this Contract by this reference,along with any applieable.3mte Supplement and Payment Summary ateaobed hereto and any Cfi:nge Orders(eollccovcly, "Contract): JoD7t (lnmo.rsero®ej Prodarit+s' S ec'9hec C(A)#: Pro act Amoune Roofing LJSiding EJ Windows Insulation 9 Qcntmers/co.,ois []Sorry Doors 9- $ Roorrng Mift W?'mdown EJ lireulatioa pqutt=-/wtCM Qsn-yJ :p - LL $ Roo5vs Sitting 0-'Windo v 01asularion $ . ❑Gtrtrcta Covas•[]Fnay Doors p- Roofing Siaim windows 0 Insulation . 'pcutietro/Covcrii pGotry 1>oorv.p - $ • MhtlmamZWo.Dopasi gCov"-Amomtdoaumueseeulianoffleaauatract •- Total ContractAinounr Q Maine Parchux.M wW notdmwrmmt than onathlid of rho ContraetAmoanL $ Customer moon:that,immediately upon completion•o£thc.work for each Product,Customer will txetute x Completion Certificate (ono for each Product as defined by an individual•'Spee Sheet)and pay ady'bala-ce due,' As applicable,each Customer under Ns Cconaet agrees to be jointly and severally obligalcdand liable hereunder. The Hoare Depot reserves the right to issue a Chango Order or.terminate this Contract or any individual Products(s)included herein,at is discretion,if The Homo Dcpot 0r iu,authorizcd scrViCC provider detormi cs that it cannot perfOnn,ita oill4utions due.was tructural problem with tho.bomc,cavitotatncnbl hamv&sucli as.mold,asbestov,or,lead paint,other safety concerns,pricing crrots or bccamw work required to eorapigte the job was not ioeluded in the Contract. 'Payment Summary- The Payment Summary inoluded as part of this Contract, sets'forth the tom' Con-act amount and payments required for 4be-dcpoxivi and•final.payment,t by Product<- applicable)-NOTICE TO CUSTOMER You are enttaed:to a completely filled-in copy of the Contract-at the dme you Agn, Do not sign a ComplctiOR Certificate(Doter there is one Completion Certificate for cacti fisted Product as defined by individual Spec Sheets)before work on that Product is complete.. lit the event of teradnatfon of this Contract;Customer agrees.to pay The home Depot the costs of materials,labor,cspenscs and services provided by The Home Depot or Authorized Service Provider through the date of termination,plus arty other nritounts set forth in this Agreement or allowed under upplicablo law. nM)F(OM9 DEPOT MAY WMTHOLD AMOUNTS OWED TO THE.HOME*DEPOT FROM THE DEPOSIT PAYMENT OR OTHM PAYMENTS MADE, WITHOUT LIMITING THE HOME DEPOT'S OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. Accantnnce-nnd Authorisatinm Customer agrees and undettttands thnt this Agreement is the entire agreement be woes Colomrr and The Hoare Depot with regard to-the Products and Insta➢a ion services and supersedes an prior discussions and agr+ccmcnts,either . oral or•written,-relotink to said Produces and Installation.This Agreement c;mnot be assigped or amended except by a writing signed by Ctietomcr anddl'hc Home Depot.Customer ackrrowledgN and agrees that Customer has reed,undersunds,voluntarily accepts to tmw of and has received a copy of this Agreement. -.A tcd.b3"-�--- tx%Signautre Date Salty Cooattltant's Signamte Date X -- .T,elophone No. u Q 1 Cutxomer's Signature Date Salty Coasulmut Lioeasc No. CATTCELLATTON CVST'OMER MAV CANCEL..THIS (asappl,-btr). AGR)E)f.1ENT WTPHOUT PENALTY OR OBLIGATION -BY DELIVERING WRITTEN NOTICE TO THE HOME DEPOT BY MTDNIGl1'T ON THE THIRID'BUSWESS DAY AFTER SIGNING THIS AGREEMENT. THE STATE SUPPLEMENT ATTACHED HEREW CbNTAINS A FORM TO USE If ONE 15 SPECIFICALLY PRESCRIBED BY LAW EN CUSTOMER'S STATE- NOM-9;ADDITIONAL TERM AND CONDITIONS ARE STATED ON T=REVEILSx SMEAN0 ARE PART O1:TOISCONTRACT of r Town of Barnstable ' *Permit p Expires 6 manlks fr' o a dot Regulatory Services Fee cb m.+s 1639. Thomas F. Geiler,Director . 9 `� AAA'1 Building Division .Tom Perry, CBO, Building Commissioner �(1' 200 Main Street,Hyannis,MA 02601 / www.town.bamstable.ma.us Office: 508-8 62-403 8 Fax: 50 8-790-623 0 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number ' I Pro rty Address Residential Value of Work ,// 7 e Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address E'i Z Ae T A / /t�/le� '�fY) e Contractor's NameT#0 AJ&ln c SeWce. A' - Ae VI'o >l Telephone NurnberE08"/01 Home Improvement Contractor License#(if applicable) (� 8 J TQ9�3 rWorkman's coon Supervisor's License#(if applicable) TO� �� PERMI Compensation Insurance 2012 Check one: MAR 2 U ❑ I a sole proprietor am the Homeowner I have Worker's Compensation Insuranc Q�� of BARNSTAB�E T insurance Company Name Nw- Alnp,Z�1, v�orkman's Comp. Policy# 00 6 7� -opy of Insurance ompliance Certificate must accompany each permit. 'ermit Reque check box) Re-roof(stripping old shingles) All construction debris will be taken to P/1 M atl�l ❑Re-roof(not stripping. Going-over existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/sliders. U-Value (maximum .44)#of windows *What: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 require GNATURE: Wnt:tt cctt:nut tet►..,:t.t;.,,..., :. .Ott vnv t ce a. f ` The Commonwealth of Massachusetts Department of Industrial Accidents Office of Invesdgadons ' 600 Washington Street Boston,AM 02111 www massgov/dia Workers' Compensation Insurance Affldavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le0bly Name(Business/Organization/Individual): __H0 Al 1?e4o:L Address: ce 5 err o City/State/Zip: "4rt, �o 3 0 3 Phone#: Are you an employer? Check the A ppropriate rIam Type of project(required): 1.,�' I am a employer with i 4. a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. Q Demolition working for me in any capacity. employees and have workers' insurance.z 9. ❑Building addition comp.[No workers' comp.insurance 10.❑ Elec cal repairs or additions required.] 5. Q.We are a corporation and its 3.❑ I am a homeowner doing all work officers have exercised their 11.Q IP bing 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. ;Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that isproviding workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: " s o , Policy#or Self-ins.Lic.#: w C o 1 g 7 3 6 2 /yr Expiration Date: 3 Job Site Address: Ala �►A/ ��� ' /, 1 �� City/State/Zip-tA ! A4, 0- 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$i,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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify and airs and penal perjury that the information provided above is true /and correct Sl e' Date: o�V Phone#: O,jj?cial use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of health 2.Building Department 3.City/Town Clerk"4.EIectrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#:i, zr, v' ,p►� //w -eamm wawald a�✓ wac�ucsel a Office of Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR � 1 �26-�$..9 3 ..- Type:Registration; Exi Supplement ,_5e!The Home De o0�•_t= d� S' _nnces DARREN DEMEF ,S' - 2690 CUMBERLAND F' RCVUAY S GA 3033g' Undersecretary - r License or registration valid for individul use only before the expiration"date. 'If found return to: Office of Consumer Affairs'and Business Regulation , 10 Park Plaza—Suite 5170 �;ard Boston,MA 02116 Not valid without signature yJ DATE;RA-I'Dwrrep ACORD CERTIFOCATE OF LIABILITY IMSURANCE MATTER OF Jow WRIZIONZI IN$ AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CER'nFICATS DOZ5 NOT ARM SO, 9ATEND OR UA-M --!'010 :AMATT�CRMMAI ALTfR THE COVERAGE AFFORME) BY THE POLICIES BELOVW- 75 7 STA52T KULL, MM, 020AS INZURE"AFFORDING COVERAGE NAIC 0 INSURER A: Miahmal Viola M W- STB STATE XN6 8 IRvAlassah Way IN41.7m C: Rull, HA 02045 COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BFtPj [&$UFD TO '(Hf INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT wni RE8PFCT 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 SUC!-I POLICIES.AGGREGATE.L1mrrS SHOWN MAY HAVE BEEN REDUCED BY PAID CLARMS. —7u9w-0wff6A17 LTR N820 T" I—nuk"cs POLICY uwtmn oxm(NW00A.4— 12ATr jummw QF4— " GENERAL UAUaJIY RACHO=VRRENCV Am cm c3ENE;tAL.uAmLrry PRC 4ISE8(Fa owumm) CLAMMAOS [_j OCCUR &RD EXP tAAY*hf)P&CEM) PeR$0NAL 4 ADV fWURY 3 GINMALAGGREGATE GF14L AMRE-OATE LIMIT APPL398 FUt fflOVt.=G-COMPMP AGG 5 7 POLICY OPRO- r ED Loc AUTOWD5"L1AWLSY CDMgrqEO MLF UNOY (Sa fitodwo ANY AUTO ALL QWNr0 AUTOS OWLY tNiukv HIRWAVIM O*Cr&Y AWAY 1a (Pot awtdom) PROP6M 13AMAaE Ipw awwm* umurf ANY AUTO 0714tATMAN FA ACC 8 AUTO ONLY; AUG $ axtntfumaRM.LA L"Itm OCCUR u CLAMS MADE AGaRCOATE I bEDUMBLa -4 I RETENTION 8 iJ fAtOkKERS COMPMATION AND WC-6484161- LMPLOYM,uAnni" 5/26/.2011- 5/26/2012 IEJ-MHACQDaHY 2100000 ANY PROPMETOWARIMPUMECUT11a OFFMampmm H.L.01MAGE-PA EMPLOYEE $500000 P-L 01011"i-POLICY LIMIT I a 100000 SPECIAL PROVISIONS pilwf OTHER InCRIPT104 OF OPA0AMW1jOCATIWM/1)V=M1 EXIOUIDIONS ADM 13Y E,7m—.xm0—Ew16PEC%AL PROVISIONS .............. Tfib SERVICE,8', XAC. AM T?M HOM IDEPOi 'P'-R-Z INCLVlJEU""A-*'$-"A"'D'D--ITX(,�N-i.LINSURFM WITH RESIVECT TO GENERAL LIABILITY INSMANCE. :ERTIFICATE HOLDER CANCELLATION SAOULP ANY 0? YHt ABOVE I)MCM111 VOUG138 BE CANCEL40 09FORA THE "PIRATION . ............................... THD AT-HiMa GATE THMOF. TH22 1699IN0 IMURM WILL rOVEAVOR 710 MAIL_DAVS WPJY"-M 2690 Ctt�MydjuqD r.Al-RxwAy SUITE 30() NOTICE To THE CWTIACATE R010011 KAMM TO TH2 U[Pt, BUT 1`41JUR9 TO 00 SO SHALL ATLANTA, GgOlke.IA - WOWS No 0KJvA7wN OR L"MY OF ANY TM RAURFIZ. Im AQUAITS OR as(a *j?N-) n C40.11PORATION 1988 VWJ 0n:OT (IT07iTO/00 Massachusetts Department of Public Safety --� Board of Building Regulations and Standards i)mtruCtil�n Sii' ervi-sor Specialty License.: CSSL-099403' � 1�.77. 1 f N y s IdIICHAEL J VIOLA '` x 8 HADASSAH WAY ' H ' HULL MA U2045 Expiration Commissioner 02/24/2014 i Iw- _ Office of Consumer Affairs and'Business Regulation 10 Park Plaza- Suite 5170 BostonNassachusetts 02116 Home Improvement Contractor Registration Registration: 140993 Type: Individual t f Expiration: 12/17/2013 Tr# 219072 MICHAEL J. VIOLA xY MICHAEL VIOLA -- 8 HADASSAH WAY - F HULL, MA 02045 --- - --- -- Update Address and return card.Mark reason.for change. L—I Address ('� Renewal �:VI Employment Lost Card UPS-CA1 Co 5CM-04/04-G101216 ;l�P. -fp09JLJJ2lYILlG6lLG'UL IJ�i��I7dJILCiLGJP.�.6 �, L =. Office of Consumer Affairs&Business Regulation }. License or registration valid for individul use only HOME.IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration =,140993 Type: f Office of Consumer Affairs and Business Regulation 10 Park Plaza-Suite 5170 "-. Expiration: 12/17/2013 Individual t: Boston,MA 02116 MICHAEL J.VIOLA,:- MICHAEL VIOLA F 1 8 HADASSAH WAY O� �'tjc.. HULL,MA 02045 Undersecretary i• Not valid without signature - I ,a Mar 16 12 03:40p Chris Read 1-508-681-8800 p.1 HOfviF,IMPROVEMENT CONTRACT PLEASE READ THIS Sold.Furnished and Installed by: Branch Name: Boston Date: THD Al-Home Services.Inc. d/h/a The Home Depot At-Humc Services USA Greenwood Sirce-L Unil2.Worcester.MA 4)IMP Toll Free(8(10)05'-5182:Fax(50K)756-8823 Stanch Number:31 Federal ID#75-26994( :Nlh Lie k C 02439:RI Cont..Lie#Ih317 ("1'Lie#H1C tWiS 5?T WA Runic lmpmvemcnf Coonnira.inr Reg.#12M93 Installation Address: /& /� ��/�� 5� �0ie� 7'+="" �, '' n` '��� City Sta VICIA4 n Imp Purehaser(s): Work Phone: Horne Phone: Cell Phone: Home Address: Slate Tp (If different from Itts[:illation Address) City F.•mail Address(to receive project communications and Home Depot upsies): 1 DO NOT wish to receive any marketing emails from The Home Depot Proiect information: Undersigned("Customer"),the owners of the property located at the above installation address.agrees to bu). and THD At-Home Services,h e.("The Home Depot"):tgreus to furnish,deliver anti atringe for the installation("Installation"')of all ivawrials de-scribed on the below and on file referenced Spa:Sheet(s),all Of which are incorporated into this Contract by this reference,alone with uny applicable State Supplement and Payment Sununary uttuched hereto and:my Change Orders(collectively, "Contract"): Job#: neearroemt.r..mc« Products: Spec Sheet(s)4: ProiectAmounl unfing ❑Siding Windows ❑Insulation l ❑Gutters/Covers ❑Entry Doors ❑ Q( I/P Rooftno uSiding Windows LJ Insulation ❑Guucrs/Coven ❑Entry Doan ❑ _. ❑Roofing OSiding ❑\Yinduws Insulation ❑Gaiters/Cuvcn ❑Entry Doors.n Rafin- ❑Siding Aindmvs ❑Insulation S ❑Gutters/Covers ❑Entry Dexen ❑_ Ntininum25%DcplsitofContractAmountdueuponacauhcco°tthiscontract' Total Contract Amount $ Itlaine Pun hascrs may,not deposit mac than mn third of the Gmunct Amount. / Customer agrees tha(,immedialcly upon completion of the work for each Product,Customer will execute a Completion Certificate lone liar each Product as;defined by an individual Spec Sheet)and paw any halanee due. As applicable,each Customer under the Contract agrees to he jointly and severally obligated and liable hereunder. The Home Depot reserves the right to issue a Change Omer or terminate this Contract or any individual Prcxtuct(s)included herein.at ifs discrxiun,if The Home Depot or its authorized service provider determines that it cannot p rRlrm i1S oblie:nions due to a slrticturd problem with the home.environmental hazards such as mold.asbestos or lead paint.other safety concerns,pricing omits or because work required it)complete the job was not included in the Contract. Pavment Summary The Payment Summary#--- � included as part of this C'nntrtct. sets firth the Lutsl Contract anwuat anti payments required for the deposits and final payments by Product(ats applicable.). NOTICL TO CUSTONIE R You are entitled to a Lompletely idled-in copy of it*Contract at the time you sign. Do not sign a Completion Certificate(note: there is one Completion Certificate for each listed Product as defined by individual Spec Sltceh)before tvorh on that Product is complete. in the event of termination(of this Contract,Customer agrees to pay The Home Depot the cosh;of materials,labor,expenses and servlces provided by The Home Depot or Authorized Service Provider through the date of termination,plus any(other amounts set forth in this Agreement or allowed under applicable law. THE HOME.DEPOT MAY WITHHOLD AMOUNTS OWED TO THIS HOME DEPOT FROM "rHE DEPOSiT PAYMENT OR OTHER PAYMENTS MADF, WITHOUT LIMITING THE:HOME DBPOTIS OTHER RENIEDIFS FOR RECOVERY OF SUCH AMOUNTS. Acceptance and Authorization_: Customer agrees and understands that Ibis Agrca;mcnt is file entire.agrecnnanl beuvecu CusMill,r :rod The Humc Depot with regard to the Products aril lnSWlla lion services unJ supe tactics all print di>cussiuns and agreuumcnls,cith.r oral or written,relating to said Proclucw and Installation.This Agreement cannol he assigned or a inendcd except by a writing signed by Customer and The Home Depot.Customer acknuwludgcs and agrees that Cusittnner has read,understand%,voluntarily ucerpts tin terms ul'and has received it copy of this Agreement. Accepted by: Submitted At Dante Sales nnsu tant's Signature Date Custom s Signature /� _ ��//������ x Telephone No.,�-6�14, -!_/ Customer's Signature Date Sales Consultant license No. h:y+Plicahk•t CANCELLATION: CUSTOMER MAY CANCM. THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRIT`l'hN NOTICE TO THE HOME DEPOT iiY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING THIS AGREF.MEN'r. THE STATE SJ1pP1XMFNT ATTACHED HNRETO CONTAINS A K)RM 1Y) USE iF ONE, IS SPECIFiCAL),Y pRESCRIBEA BY LAW IN CUSTOMER'S STATi1 Nt1.1'1('F.:ADDITIr INA1,TI:RMS AND t•ONI)rnoN.,;AIW S PATI{D ON Tl1N RP:X9ULS);SIDE.AND ARE PART fiF•1111S CON 1111\t'r 10-04-11 C-SC White-Branch File Ye11ow•-C.uSlecwr Assessor's office(1st Floor): l 7 C SEPTIC SYSTEM MUST BE � `TME t Assessor's map and lot number .� � �o Board of Health(3rd floor): �^ INSTALLED IN COMPLIANCE' Sewage Permit number BSBa9TSBLL J Engineering Department(3rd floor): ENVIRONMENTAL CODE AND , rasa House number TOWN REGULATIONS '�''�'°'°• Definitive Plan Approved by Planning Board 19 C NAY APPLICATIONS PROCESSED 8:30-9:30 A.M.and 1:00-2:00 P.M.only TOWN OF BARNSTABLE BUILDINVi" INSPECTOR APPLICATION FOR PERMIT TO TYPE OF CONSTRUCTION (0 0C)C( 19 � TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location Proposed Use S� Zoning District � / Fire District Name of Owner C -�-} j Z e e l N / 1/J/ Address )Llo/O — Name of Builder �) ,(�i9 /�� Address ®/� � �GvA/ Cl>,gX)ekS74 Name of Architect ��.� Address ` I3gG?N S7i Number of Rooms Foundation Exterior Roofing Floors SJ� Interior Heating Plumbing n Q):SX 'FireplaceAZ0-22le Approximate Cost U Area �a �o Diagram of Lot anc Building with Dimensions Fee -' I ' aye Z Y J W^,'ti OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name AA a C/ Construction Supervisor's License O 7 5 3 S i ter- MILLER, GREG & ELIZABETH N' ,r q s ` BUILD FRAME No 3 3 0 3 2 Permit For GARAGE �• �` Accessory To Dwelling }` Location 1610 RbA ^ West Barnstable Owner 'Greg & Elizabeth Miller ' Type of Construction Wood Frame ;s Plot � Lot Permit.Granted July 5 1989 Date of Inspection" ` Go-?19 to Coml ted 19 - Pm 0 G` tK E ,; fit '' Assessor's map and lot number .Ma.p. #1r.....L.ot...#23 Sewage'0e41t number �(.Ur CC- SA Eros° v w • TOWN OF BARNSTABLE [y., BARNSTABLE, i "ABILr�� � 039- Ep ypY [v �, BU [LDIN.G INSPECTOR ' a• � [L T a• e APPLICATIO _� Re=construction of rear entr to dwell in N, FOR"PERMIT TO y .�a Frame construction; natural cedar shingles eateriol; TYPEOF CONSTRUCTION ................................................................................................................�........�.......... ...................1?A V.7. ........19........ TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Rte.6A - W.Barnstable Location ....................................................................................................................................................................................... Proposed Use Back entry, "Mud room" to dwe.l.11.r�g,...................... .................. ........................................................... ZoningDistrict ........................................................................Eire District .............................................................................. Plumwood Trust, Name of Owner Albert E. Ronde.au.,...Tru,steB,Address .....RtA,...6A .................... Robt. Butler 33 Fd�ewood Rd . Harwich Port Nameof Builder ....................................................................Address ..............s7.................................................................... Nameof Architect ...................................................................Address .................................................................................... Number of Rooms ---4 one, 12' X 13 r 8".) Foundation .....cement block .............................................................. .................. Exterior naaangle ....Roofin.... g ................ced.....r.........shi.... g ......�.�( (�. . ...................... Floors Armstrong type, kitchen tile. Interior ..,plaster board . ...................................................................... [ Heating ......................Plumbing ........ ---- N.Q .................................Approximate Cost a�G-�sUB`O Fireplace ....................... . 1R Qom.......... Definitive Plan Approved by Planning Board -------------------_-----------19________: Area ..1.56..s q.f t.•.....:....... Diagram of Lot and Building with Dimensions Fee �D ....�'................................ SUBJECT TO APPROVAL OF BOARD OF HEALTH o#4 I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name Rondeao, Albert E. , ' ^ ` 18908 add to a1ogla No .................'Permit for..................................... � family dwelling - ~ - ;---------------.. ------.. ` ^ Locution ................... . West Barnstable' ................................................. Albert E. Rmndeam Owner ............. ................. — ..........................— ' frame � +` ` Tvno of Construction -------------- --------------------------' � . Plot .......................... Lot ----------'' ` ` J�ooa�y �� � 77 - ^ ' Permit Granted ---------.�---.lA � ' � �oteof4nspec�on lg � ~ ---. --.� . � ( � �.bate Completed �..�.—',]g `- . . . . ` ^ - ^ PERMIT REFUSED . � ' -----_----------. --. lA ' ' . -----~-------------------- . ^ � ' - ' ....................................... -----.�--.,----. . ^ , - ------------------.-.----..��. ` ^ . ...................--------------.—...—_ ` . ^ . ' ' Approved _-----------.........�lA ' . . ^ ----------------.--,------.. ' - -------------------------- ` . K � Assessor's map and lot number .....#1.97.....LO- {}'2 IA�t'G'G. / Sewage Permit number ......................i�i(/T TG ........................... °`T"E'°�. TOWN 'OF BARNSTABLE i i BA"STOBLE, i 16 9- �e� BUILDING INSPECTOR �o M Re-construction of rear Pntry to d,,;-lli.nq,. APPLICATION FOR PERMIT TO ... ........................................................................................................ Frame construction; natural cedar , r# TYPE OF CONSTRUCTION ......................................................................................................shinzl.........:.......ps.. ....Q..gterio.... 12/l3/7E TO THE INSPECTOR OF BUILDINGS: - The undersigned hereby applies for a permit according to the following information: Rte.6A - W. Barnstable Location ..................................................:..................................................................................................................................... Proposed Use Back ey, "mu ro " d . ......................ntr....................d............om........to...................welling............................................................................................ ZoningDistrict ..............................Fire District ..................................................... ....................................... Plurnwood Trust , Name of Owner Albert T Q Rondeau, 1'rus.tee.Address .....Rte. 6A - W,Barnsteble .................. .................................................................... Robt. Butler 33 Fdgewood Rd . �.t fort • Name of Builder ....................................................................Address ........................................:.......................... . .. . . .......... Nameof Architect ..........................!.......................................Address .................................................................................... Number of Rooms ......---4 one, 121 X 131 8t') cement block ....... ........................... ............Foundation ............................. natural cedar shingle ; t- Exienor ....................................................................................Roofing ......;.�..�..._..:......,..:......................................................... Floors Arm8trong type, kitchen tile . Interior ... ?laster...b.oard. ... .. .... .. ................................................ ' ..........Plumbing '` '—"— ........................A Approximate Cost Fireplace � � pp .................................�.................................. Definitive Plan Approved by Planning Board -----------_-._--_-----------19--------. Area ..J.56 R.r.e.f t.�............... Diagram of Lot and Building with Dimensions ' Fee ................................. SUBJECT TO APPROVAL OF -BOARD OF HEALTH I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name(,... .� ....t,,�1/.� .�//.�f. . Rondeau, Albert A=197-23 18908 add to single No ................. Permit for .................................... family dwelling . ............................................................................... Location ............................. .... West Barnstable ............................................................................... Albert Rondeau Owner .................................................................. Type frame.of Conitruction ........... ............................... ................................................................................ Plot ............................ Lot .................................. Permit Granted ............JAiugxy...6........19 77 Date ofAnspection ....................................19 Date Completed .................................. ...19 PERMIT REFUSED ... ... . .. ................. .I.. ...................... 19 .................... . ...... ....... ... .. ..... ... ....0.............. .......................................... .......... ......................... ............................................................................... . ................. .......................................... Approved ...............................................L-19-, ................................................................................... ............................................................................... Assessor's office(1st Floor): Assessor's map and lot number t �o*THE Board of Health(3rd floor): d�Q #� Sewage Permit number Z BAHd91'O.OLL i Engineering Department(3rd floor): roes House number. n °o 'b}9 \e�' Definitive Plan Approved by Planning Board 19 ;, •�o raY A, , APPLICATIONS,PROCESSED 8:30-9:30 A.M.and 1:00-2:60 P.M.only BAR T BLE _TOWN OF NS A � BUI-LDING INSPECTOR y APPLICATION FOR PERMIT TOr TYPE OF CONSTRUCTION GUOOCJ T-t • t .I�I '19 TO THE INSPECTOR OF BUILDINGS: , The undersigned hereby applies for a permit according to the following information: Location �ro ti U1/ �j1 AK7",41? Proposed Use 44 T?/4 Zoning District + Fire District n.,�- 4 Name of Owner l � �` rl, Z elP l,n / / Address � /C� /r 6,4 • Name of Builder \�C o�r cX a T1" v� Address Name of Architect 1 1 f Address 1J���N S7!7 /P 01,1//¢S� Number of Rooms Foundation �/ 4.4Exterior 0) . el� S �� Roofing � �� A � ...t � Floors S/R Interior Heating Plumbing Hp Fireplace Approximate-Cost • Area ' Diagram of Lot and Building with Dimensions Fee.; • 3y ay ,t i OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name Construction Supervisor's License MILLER, GREG & ELIZABETH G A=197-023 BUILD FRAME No 33032 Permit For GARAGE Accessory to dwelling Location 1610 E A :> I West Barnstable Owner Greg & Elizabeth Miller j Type of Construction Wood Frame t Plot .Lot Permit Granted July 5 19 89 Date of Inspection 19 Date Completed �19 Parcel Detail Page 1 of 3 Nomi 314 A.a@�y� I 'C (_"a _� 4` t�f} j ,��JJ-/�/ r•r � ALh55, Logged In As: Parcel Detail Wednesday, December 2 2009 Parcel Lookup Parcel Info Developer I Parcel ID 197-023 Lot 1 Location 11610 MAIN ST./RTE 6A(W.BARN.) Pri Frontage 109 Sec Road I Sec Frontage Village IWEST BARNSTABLE I Fire District JW BARNSTABLE Sewer Acct I Road Index 0955 �vim•W��$�- ..r .,,, Asbullt Septic Scan: Interactive 197023_1 Ma Owner Info Owner IMILLER, ELIZABETH C TR I Co-owner jKYA REALTY TRUST I Streets 11610 MAIN ST ( Street2 1 �I City JW BARNSTABLE I State lMAI zip 02668 I Country Land Info Acres 17.92 use ISingle Fam MDL-01 I Zoning I RF Nghbd 0108 Topography Level I Road Paved I Utilities Gas,Weil,Septic I Location lWater View Construction Info Building 1 of 1 Year 1840 I Roof Gable/Hip ( Ext Wood Shingle Built Struct Wall Effect 1872 I Roof Asph/F GIs/Cmp ( AC None Area Cover Type 9' In Bed style I Conventional I wall Plastered I Rooms 3 Bedrooms Int Bath d t M Model lResidential I Floor I Rooms 1 Fu►I+ 1 H 0' Total Grade Average type Hot Air ( Rooms 8 Rooms Stories 12 Stories � Heat I Fuel Oil I F ation Typical Permit History Issue Date Purpose Permit# Amount Insp Date Comments http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=14239 12/2/2009 Parcel Detail Page 2 of 3 1107/01/1989 I I B33032 I$30,000 I01/15/1990 00:00:00 I WB GARAGE II Visit History Date Who Purpose 05/01/2000 00:00:00 Paul Talbot Meas/Listed-Interior Access Sales History Line Sale Date Owner Book/Page Sale Price 1 10/02/2002 MILLER, ELIZABETH C TR 15688/246 $1 2 10/01/2001 MILLER, ELIZABETH C 14288/162 $1 3 05/15/1988 MILLER, GREGORY K& ELIZABETH C 6284/019 $255,000 4 RONDEAU,ALBERT JR E 1580/016 $0 Assessment History Save# Year Building Value XF Value OB Value Land Value Total Parcel Value 1 2009 $163,500 $2,300 $20,100 $313,000 $498,900 2 2008 $163,500 $2,300 $20,100 $349,500 $535,400 4 2007 $163,500 $2,300 $20,100 $349,500 $535,400 5 2006 $146,200 $2,300 $20,600 $345,400 $514,500 6 2005 $136,100 $2,300 $21,100 $230,300 $389,800 7 2004 $114,000 $2,300 $21,300 $230,300 $367,900 8 2003 $95,000 $2,300 $21,800 $153,400 $272,500 9 2002 $95,000 $2,300 $21,800 $153,400 $272,500 10 2001 $95,000 $2,400 $21,800 $153,400 $272,600 11 2000 $72,600 $2,300 $18,800 $69,100 $162,800 12 1999 $72,600 $2,300 $15,000 $69,100 $159,000 13 1998 $72,600 $2,300 $15,000 $68,500 $158,400 14 1997 $80,800 $0 $0 $70,700 $159,900 15 1996 $80,800 $0 $0 $70,700 $159,900 16 1995 $80,800 $0 $0 $70,700 $159,900 17 1994 $77,400 $0 $0 $63,900 $149,900 18 1993 $77,400 $0 $0 $66,700 $152,700 19 1992 $88,200 $0 $0 $70,700 $168,700 20 1991 $73,400 $0 $0 $155,600 $244,400 21 1990 $73,400 $0 $0 $155,600 $229,000 22 1989 $73,400 $0 $0 $155,600 $229,000 23 1988 $68,300 $0 $0 $120,700 $189,000 24 1987 $68,300 $0 $0 $120,700 $189,000 25 1986 $68,300 $0 $0 $120,700 $189,000 w. Photos http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=14239 12/2/2009 DetailParcel P, . - oanerzoos -`� ` � .«» r 'p«w .t:lirs w 'r fit:,;,�,. ,�;J� �,,,•i w OflnBR0U9 ��'Y'4a, x �2 •Vic''„ r r , r i � t • } j ' � r r i i V�~ i I � a i b 11T �.4t3c�tC .. I ii I dL 1 CTP .Fl L L 1 7-7