HomeMy WebLinkAbout1630 MAIN ST./RTE 6A(W.BARN.) 30 iT 4�tl* / ST
UPC 12543
No. 53LOR
HASTINGS, UN
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StY
'.'.'.RONT1ER '
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........ mr Solutions,
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Date: 1 "
Thomas Perry, CBO
Building Division
200 Main Street
Hyannis, MA 02601
RE: Insulation Permits
Dear Mr. Perry,
This affidavit is to certify that all wor com leted at:
� _ W�
has been inspected by a certified Yuildi6g Performance Institute (BPI) Inspector. All work
performed meets or exceeds federal and state requirements.
Permit application number: 20120-7 I
Issue date:
Sincerely,
Francis She -+
President o `�
Frontier Energy Solutions, Inc.
Office- 774-237-0410
�I
Email: fssfrontierenrgy@gmail.com =d
�'
oF�rar
Town of Barnstable *Permit 401 q0I (55�
- Expires 6 r ninths from issue date
Regulatory Services Fe
• B"NSPAB14
9� MASS. $ Richard V.Scali,Interim Director
039. ♦�
ABED��A
Building Division
Tom Perry,CBO,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.bamstable.ma.us
Office: 508-862-403 8 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number
Property Address C/76 A o,;' 9k K'A . LS n ar►1
Xj Residential Value of Work$ J�.?cif), u d Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address �� ��✓y J' �7 GC/, Y! /14 'W4
Contractor's Name 06 f /1414 Aq4j-14 Telephone Number
Home Improvement Contractor License#(if applicable) Email:
Construction Supervisor's License#(if applicable) Q - Qa 9y�
❑Workman's Compensation Insurance
Check one: XsPR S PERMIT
DQ I am a sole proprietor
❑ I am the Homeowner
❑ I have Worker's Compensation Insurance FEB.2 0 2014
Insurance Company Name
Workman's Comp.Policy# TOWN OF BARNSTABLE
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box)
[� Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ZV&4 Ign4.6;11
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
Q Re-side
❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#of windows
#of doors:
❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required.
Separate Electrical&Fire Permits required.
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License&Construction Supervisors License is
req fired
SIGNATURE: G
Q:\WPFILES\FORMS\building permit forms\E)PRE/do,
Revised 061313
The Commonww4dth of 11�iassackusetts
Department of Industrial Accidents
Office of Invesugaftons
600 Washington Street
„ Boston,CIA 02111
nm v mass_gov/dia
Workers' Compensatian hmar ance Affidavit Builders/Contr.-actors/Electricians/Plvmbers
Applicant Information / Please Print Legibly
Name MusmessmTgmizationandiviaaat): �i[�Car�� �y9G�rlc1
Address:
City/State 7-ap: Ar4AZ ,&SS d2KWPhonelk SD d - !Kl�
Are you an employer?Check the appropriate box: T of project r
4. I am a general contractor and I Type P ] ( �"e�
1.❑ I am a employer with ❑ g 6. ❑New construction
employees(full andlor pact-time).* have hired the sub-contractors
2.® I am a sale proprietor or partner-
listed on the attached sheet. 7- ❑Remodeling
; ship and have no employees These sub-contractors hate 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_❑Electacal repairs or additions
3111 am a homeowner doing all work officers have exercised their I ❑Plumbing repairs or additions
myself[No workers'comp- right of exemption per MGL 12.,❑Roof repairs
insurance required.]T c.152,§1(4X and we have no
employees.[No workers' 13.0 Other at �/a/J 0ot ed I
comp.insurance required.]. /P e tc%�'eit!Ti/il'1
''Piny applies that checks box#1 most also fill out the section below showing rhea woakers'compensation policy infflrmatim
I Homeowners who subunit this affidavit indicating they are doing all woA and then,hire outside contractors r>m'submit a new affidavit indicating such.
FContractors that cback this boat must attached an additional sheet showing the name of the sub-ccuttactots and stare whether"nut those entities have
employees. Ifthe sub-wntactots have employees,they must provide their workers'camp.policy number.
lam an employer that is prmiding ttrorkers'congmusation insurance for lily empioy,ees. Below is the policy and job site
information.
Insurance Company Name:
Policy 9 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 andlor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDERand a fine
of up to$250.00 a day against the-violator. Be advised that a copy of this statement may be fDrwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby ce►Yrf, rider he 'ns andpenaities ofpedu.ty-that the information pratrided abmre is true and correct
r
S" Date:
Phone 9: Z
O,,(jicial use only. Do not write in this area,to be completed by city or town official
City or Town: PermitlLicense if
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cit)TFown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone it:
6
3
Town of Barnstable
Regulatory Services
MAM �, Richard V.Scali,Interim Director
i639. ♦0
'fin Mop' 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 Owner Must
Complete and Sign This Section
If Using A Builder
I, I , as Owner of the subject property
hereby authorize ��6AGt►//I 0 jey7 to act on my behalf,
in all matters relative to work authorized by this building permit
(Address of Job)
**Pool fences and alarms are the responsibility of the applicant. Pools
are not to be filled or utilized before fence is installed and all final
inspections are performed and accepted.
Signature of Owner Signature of Applic t
Print Name Print Name
I
Date
Q:FORM&OWNERPERMISSIONPOOLS 10113
Town of Barnstable
Regulatory Services
pfcTHE Teti Richard V.Scali,Interim Director
Building Division
BARMNSUBM MASS, Tom Perry,Building Commissioner
9 1639, �e�.� 200 Main Street, Hyannis,MA 02601'OrEn � www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6250
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.
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 061313
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\ 1 Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor
License: CS-063941
RICHARD P FOG,&RTY
254 W -�,-
AI.NUT STr-
MARSTONS MILY,S 1VIA�`U2648 ,
Expiration
Commissioner 11/11/2014
Parcel Detail Page 1 of 3
t BAR45TAttLE,
MASS, - ,
GiJI `
Logged In As: Parcel Detail Wednesday, December 2 2009
Parcel Lookup
Parcel Info
l Developer l
Parcel ID 197-024 Lot
Location 11630 MAIN ST./RTE 6A(W.BARN.) l Pri Frontage 1141
Sec Road l Sec l
Frontage
Village IWEST BARNSTABLE Fire District W BARNSTABLE
Sewer Acct l Road Index 0955 l
Asbuilt S Sep
tic c can:
P Interactive
197024 1 Mapes� r
Owner Info _
Owner ISYkIALA,CARL F&STEPHEN P ( Co-owner jC/O SYRIALA, EDITH L l
Streetl 1630 MAIN STREET Street2 j l
city JW BARNSTABLE , State MA I zip 02668 Country
Land Info
Acres 10.88 use ISingle Fam MDL-01 ( zoning JRF Nghbd 0108
Topography Level l Road Paved l
Utilities I Gas,Well,Septic l Location l
Construction Info
Building 1 of 1
Year 1928 l Roof Gable/Hip l Wood Shingle l
Built Struct WallaII
Effect 1409 l Roof Asph/F GIs/Cmp l AC None l
4,
Area Cover Type
style 1conventional l Wall Int Rooms
all I Bed 3 Bedrooms l $" M
I
Model Residential l Floor l Rooms 1 Full+ 1 H l
Grade Average Type Heat Hot Water Rooms Total 6 Rooms -"EP �:
Stories 2 Stories l Heat Oil —1 Found Typical l
Fuel ation
Permit History
Issue Date Purpose Permit# Amount Insp Date Comments
http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=14240 12/2/2009
Parcel Detail Page 2 of 3
Visit History
Date Who Purpose
1/21/2009 12:00:00 AM Karen Perry In Office Review
3/27/2008 12:00:00 AM Jeff Rudziak Abatement Review
5/16/2007 12:00:00 AM Karen Perry In Office Review
6/1/2006 12:00:00 AM Jason Streebel Abatement Review
5/1/2000 12:00:00 AM Paul Talbot Meas/Listed-Interior Access
Sales History
Line Sale Date Owner Book/Page Sale Price
1 5/20/2008 SYRIALA, CARL F&STEPHEN P 22920/333 $0
2 3/15/1990 SYRIALA, CARL F&STEPHEN P 7108/128 $1
3 6/7/1937 SYRIALA, RUSSELL F&EDITH L 528/68 $0
Assessment History
Save# Year Building Value XF Value OB Value Land Value Total Parcel Value
1 2009 $147,200 $2,400 $2,900 $225,100 $377,600
2 2008 $132,200 $2,400 $2,900 $251,400 $388,900
4 2007 $139,500 $2,400 $2,900 $251,400 $396,200
5 2006 $111,500 $2,400 $3,200 $248,400 $365,500
6 2005 $99,100 $2,300 $4,200 $165,600 $271,200
7 2004 $80,400 $2,300 $4,200 $165,600 $252,500
8 2003 $73,500 $2,300 $4,200 $67,700 $147,700
9 2002 $73,500 $2,300 $4,200 $67,700 $147,700
10 2001 $73,500 $2,400 $4,200 $67,700 $147,800
11 2000 $70,100 $2,500 $4,300 $37,700 $114,600
12 1999 $70,100 $2,500 $3,500 $37,700 $113,800
13 1998 $70,100 $2,500 $3,500 $37,700 $113,800
14 1997 $73,300 $0 $0 $37,700 $113,400
15 1996 $73,300 $0 $0 $37,700 $113,400
16 1995 $73,300 $0 $0 $37,700 $113,400
17 1994 $80,000 $0 $0 $33,900 $116,300
18 1993 $80,000 $0 $0 $33,900 $116,300
19 1992 $90,900 $0 $0 $37,700 $131,300
20 1991 $75,700 $0 $0 $84,700 $168,200
21 1990 $75,700 $0 $0 $84,700 $168,200
22 1989 $75,700 $0 $0 $84,700 $168,200
23 1988 $60,800 $0 $0 $37,300 $107,800
24 1987 $60,800 , $0 $0 $37,300 $107,800
11 25 1 1986 1 $60,800 $0 $0 $37,300 1 $107,800
Photos
http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=14240 12/2/2009
Parcel Detail Page 3 of 3
1
.�
rt ' i i
http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=14240 12/2/2009
?C)
Town of Barnstable *Permit#
Expires 6 onths fro ue date
Regulatory Services Fee
snaxszMai.s,
v� M' g Thomas F.Geiler,Director
039. ♦0
,elFD �p O,
Building Division
-PRESS�� ®M' Tom Perry,CBO, Building Commissioner
Y� 200 Main Street,Hyannis,MA 02601
Q(� www.town.bamstable.ma.us
Office: 598Q62-03;0�9 Fax: 508-790-6230
SOWN OF g3 aKXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number 1 ]O 2 Y
Property Address 430 `� '� S''� ► `��'�
P1 Residential Value of Work Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address V, '�"Y-y- .5 L/r�-�`�-
Contractor's Name l�.v JQ 4��" '" Telephone Number rQF - 3 G 2 F 7/
Cell sal- 7 3 7- 0 1 S l
Home Improvement Contractor License#(if applicable) /OZ/yq
Construction Supervisor's License#(if applicable) S `/ D c'
❑Workman's Compensation Insurance
Check one:
® I am a sole proprietor
❑ I am the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name 1?,glh,4 c X-, �n—fv KEY s.� CX
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)
❑k Re-side a q,(ram-
b #of doors
[� Replacement Windows/doors/sliders.U-Value ,3s (maximum.44)#of windows /
ire required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. .
Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License&Construction Supervisors License is
required. '
/ �0
I
i
I
+= N1its sac husetts- Depiattmenttof Public Safety^ a
Board of Buildin!� Rc!gulatiiins and Standards
Construction Supervisor 'License
License: CS 5409
Restricted to: 00
JOHN J JOHNSON
PO BOX 118a1
W BARNSTABLE, MA 02668
Expiration: 6/21/2010
< Commissioner Tr#: 28049
/�aaaczr�zu� registration valid for individul use only
Gf License or
Board of Building Regulation and Standards before the expiration date. If found return to:
egulations and Standards
HOME IMPROVEMENT.CON Board of Building R
TRACTOR Rm 1301
One Ashburton Place
Registration:y 102149 Trt# 268765 Boston,Ma.02108
Expiration_-6130/2010
Tpe Individual
lug
JOHN JOHNSON i
John Johnson J i ..� Not v id without signature
160'Church St '
PO Box 118 Administrator
W.Barnstable,MA 02668
ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE 0/0707//2009 Y)
009
PRODUCER (508)428-0440 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Mark Sylvia Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
771 Main Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Osterville MA 02655 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: Farm Family Casualty Insurance
John J Johnson
Po Box 118 INSURER B:
West Barnstable,MA 02668 INSURER C: 1
INSURER D:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR DD' POLICY NUMBER POLICY EFFECTIVEDATE POLICY EXPIRATIONLTR NSR TYPE OF INSURANCE LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
A X 2001X0201 4/16/2009 4/16/2010 DAMAGE TO RENTED 50,000
COMMERCIAL GENERAL LIABILITY PREMISES Ea occurence $
CLAIMS MADE � OCCUR MED EXP(Any one person) $ 5,000
PERSONAL&ADV INJURY $
GENERALAGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000
X POLICY PRO LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO (Ea accident) $
ALL OWNED AUTOS
BODILY INJURY
SCHEDULED AUTOS (Per person) $ 1
HIRED AUTOS
BODILY INJURY $
NON-OWNED AUTOS (Per accident)
PROPERTYDAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND O LIMITS I
O R
EMPLOYERS'LIABILITY
E.L.EACH ACCIDENT $
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $
If yes,describe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $
OTHER
1
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CARPENTRY
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
JOHN J JOHNSON DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN
PO BOX 118 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
West Barnstable,MA 02668 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KI UPON I ME INSURER,ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATI'
ACORD 25(2001/08) j ACORD RPORATION 1988
1
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):_ '16 b I t�.�n,S a---
Address:
City/State/Zip: i�: Phone #: -TOR `3 b 2 -ate 7
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 and/or part-time).* have hired the stlb-contractors 6. ❑ New construction
2.® I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
workingfor me in an capacity. employees and have workers'
y p n'• 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 I LEj 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 tll must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
]Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: / G_ &M,-% Z�s�%va,, ey
Policy#or Self-ins. Lic.M k Do2D / Expiration Date: V/t 1 o/o
Job Site Address: City/State/Zip: D,;?6 G'r
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 penalties of perjury that the information provided above is true and correct.
Signature: Date: 'e:�67, 7 o y
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
Contact Person: Phone#:
F
I 9\
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership, association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7) states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contractors)name(s), address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships (LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a.reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year, need only submit 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 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.tnass.gov/dia
A
THE Tom Town of Barnstable
an
Regulatory Services
MASS.LE I
•v nss. g, Thomas F. Geiler,Director
1 39. 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
as Owner of the subject property
hereby authorize , „ Qr to act on my behalf,
in all matters relative to work authorized by this building permit application for.
q
(Address of Job)
ecL-a 5
Signature of Owner I Date
CAAG
Print Name
If Property Owner is applying for permit please complete the
Homeowners License Exemption Form on the reverse side.
Q:FORMS:O W N ERP ERM IS S I ON
n
Town of Barnstable
o Regulatory Services
saartsr" Thomas F. Geiler,Director
Mass.
1639. ,off Building Division
TEVM�is 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
Please Print
DATE:
10B 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 aicense,provided that the owner acts as
supervisor.
DEFINITION OFHOMEOWNER
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 be/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 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\FO RM S\homeexempt.DOC
It
Town of Barnstable PRO
'TFIE Erpires 6 month fi m'ssue date
° 'ZU09 Regulatory Services Fee
• snxrisTABLE,
MASS' pS�{� Thomas F. Geiler,Director
9 O .fY
T G :`lED N1A't A
Building Division 0 6
Tom Perry,CBO, Building Commissioner R
200 Main Street,Hyannis,MA 02601
www.town.bamstable.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 N 0
Property Address / RAW l/u
[N Residential Value of Work � Minimum fee of$25.00 for work under$6000.00
,� / .
Owner's Name&Address J�t444VL, (71 G I
Contractor's Name Telephone Number^
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
i
❑Workman's Compensation Insurance
Check one:
I am a sole proprietor
I am the Homeowner
I have Worker's Compensation Insurance
I
Insurance Company Name
Workman's Comp..Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Request(check box) /
Re oof(stripping old shingles) All construction debris will be taken to 7 N P
❑ Re-roof(not stripping. Going over existing layers of roof) `
Re-sider 1
_C
A kk l2.6_ Q C YV�� #of doors
❑ Replacement 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.
Vequ
.4 the Home Improvement Contractors License&Construction Supervisors License is
SIGNATURE:
Q:\WPFILFS\FORMS\building permit orms\EXPRESS.doc
Revised 090809
•w
r�
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Z wfvm mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): ( , I--) �v✓��`�
Address:
City/State/Zip: 02 30 Phone #: 0 S°S GZ -77 5
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 constriction
employees (full and/or part-time).* have hired the sub-contractors
❑ listed on the attached sheet. 7. ❑ Remodeling
2. I am a sole proprietor or partner-
ship and have no employees These sttb-contractors have 8. ❑ 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.�Iam a homeowner doing all work officers have exercised their 1 LE] 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' 13.0 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 is providing workers'compensation insurance for my employees. Below is the policy 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 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 cer ' it der t pains and penalties of perjury that the information provided above
is true and correct.
Signature: Date: It—4 _
Phone#: _ f -s
Official rose only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone#:
Information and. Instructions '
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. .
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual,partnership,association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of an individual, partnership,association or other legal entity, employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall,not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7) states"Neither the conunonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s) of
insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a.reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit hot 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-MASSAFE
Fax # 617-727-7749
Revised 4-24-07
www.mass.gov/dia
Town of Barnstable
do
Regulatory Services
EVJtNST� hLka& Thomas F. Geiler,Director
o;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
as er of the subject property
Ir.
hereby authorize `f to act on my behalf,
in all matters relative to work authorize this building permit application for.
Azoi�
(Addres 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:FORM S:OWNERPERMISS]ON
Town of Barnstable
F�tt+e.r� `
Regulatory Services
Thomas F. Geiler,Director
awarts17"L:,
eiAss.
9� 1639. ,�� Building Division
PIED 'y 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
Please Print
v
DATE:
JOB LOCATION:l6 36 A4+tA) w p�( e,jS a b �I
nnumbe/r• street village
„HOMEOWNER": LY �L�1A11O �Pv�IOJ �i' C — 3,42 —2d 5 5�� "77` - J'Y3
name home phone# work phone tl
CURRENT MAILING ADDRESS: 3 Y/3 M I V 5 F
rx ed,0re ale M A- og6 3 D
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
' requ' men
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 dp 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\FORMSVromeexempLDOC I
I
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Y I Parcel aLl Application # Qv 1 c ( 7 �S_
Health Division Date Issued '
Conservation Division Application Fee
.:3
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation / Hyannis
Project Street Address fo ,
VillageW�S�C Ctr(('`n Lib\C�
Owner Co` �`n L�l VSU�I�ol�l r Address n(a*_�N )kqk�
r1A
Telephone (31 L4) �,3 1 '1 -
Permit Request A it an J1 m n o
-PkC d J �j • vj��� C,55 b e"f- k
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation Construction Type t C41 I,o,fA'O\
Lot Size `deb 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: 3 existing _new
Total Room Count (not including baths): existing new First Floor Room Count
Heat Type and Fuel: ❑ Gas )�f Oil ❑ Electric ❑ Other
Central Air: ❑Yes No Fireplaces: Existing New Existing wood/corm tove: Oges Q
V -po
'Detached garage: ❑ existing ❑ new size Pool: ❑ existing ❑ new size _ Barn: ❑ exiii ig ❑ new siza
:.7 i-�
Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: '=
a
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
�-r
Commercial ❑Yes ❑ No If yes, site plan review#
rn
Current Use Proposed Use }
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name C��S c^� Telephone Number 7�7 4 a3 7 0 tj (0
Address =)Do� "G\MiI CiA,1 License # ( 05q q, t
9c)/ *ky, . MA 0c�.c:�,3 ( Home Improvement Contractor# 1605 5
Worker's Compensation # CO i53(5J01 W I a
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
\3q Q,uanAnne fL,k . mw 0a6Ue
SIGNATURE A DATE ] a'
FOR OFFICIAL USE ONLY
APPLICATION#
;5 Y
7 ,'DATE_ISSUED r:
t �%MAP/PARCEL NO.
s •
ADDRESS VILLAGE
r
OWNER
f
t.
s
DATE OF INSPECTION:
FOUNDATION,JA'
FRAME
:INSULATION:'_
a
FIREPLACE
ELECTRICAL: ROUGH FINAL
i•
PLUMBING: ROUGH FINAL
:-y GAS:r,.u- ROUGH - _ 1, FINAL
._oFINAL,BUILDING %
J ,
l
ti
DATE CLOSED-OUT 3.
f
_ ASSOCIATION PLAN NO.
C y
P
_ The Commomveaith of Massachusetts
Dqwroitent Of Indus&W Acddents
Office oflnvestigadons
600 Washington Sheet
Boston,MA 02111
www M=gvv1 a
Workers' Compensation Insurance Affidavit; gmlder contract(intEledrkians/Phmibers
ADDUcant Information Please Print L
ah
Name(Bas /oon!ladlvidnal)•Address: Ma
m J a 01 Phone#: 7-74—a� 7 - 0 q I i
Are you an employer?Check the appropriate baac:
IM I am a employer with CO 4_ O:I mm a general and I
7 7/x— r
T ofprn3eetO_
employees(fall and/or part-time).* have hired the sub-coaftactcts 6. ❑New won
2.❑ I am a sole pmapriet"or.paraw- listed an the awcw sheet. 7. []Remodeling
ship and have no employees Thew sub-couttactm have B. 0 Demolition
working for m6 in any capacity. employees and bane workms'
[No wodcas' insurance comp. ,t 9. 0 Building addition
required:] 5. 0 We are a corporation and its 10-0 Electrical repairs or additions
3.0 I am a homeowner doing all work officers have exercised their 11.0 Pig or additions
myself[No wodms'comp rW of exemption per MGL I2.0 Roof repass
ice regnirEd]t c-152,§1(4),and we have no ft �
3a.❑ I on a hame�mnar as a 13. Other `,,J at�fg employees.[No vvo;kers' -
gmeral cantractbr(refer to#4) comp-, r'e4�m&]
•Any dot chedabaa#I mast d=til oar the secf=hdow theawodoa'
t Hamieawoets wlw snGmu dtis affidavit. �► -
&w ate daft all wodc and then hid:o annuaeoms rant submit anew affi f in&eming such.
:Custunesurs due ehed-this bay mint su cbed an addif oaai sbca showing the nano of toe Sub4anhuMn and state whedterornot draw en*ks have
empmgees if ft sob-aaaftema hove empioyea,they met Provide rhea 'eamp.PO&7 mmdcr-
I inn inftnu earplOyr>r that is pnvridatg tgorlras'c+o lion at4r-ance for ary emp&yms Below its dte po8ry mid job sit e
Insurance Company Name: /6�1 lLO Z !\ CC--
Policy#or Self-ins.t ic.#.- (o 3(5 C50` ( Expiration Dame~
Job Site Adar ( �3O ���� 5�. Cay/Sm�lZrp:
Attach s copy of the wortsma'compensa&n poHey dedaradon page(shower the porky awnber and expiration date]
Fannie to secure,coverage as regrdred under Section 25A of MGL c. 152 can lead to the won of cal penalties of a
fine up to g1, 00.00 and/or one-year imprisonmek as well as civil penabies in the form of a STOP WORK ORDER and a fine
of up to$250 00 a day against the violates Be advised that a copy of tbis swenng may be farwa nW to the Office of
Investigations of the DIA for hmw=cevemge verification.
I do hereby tinder pains and pmalties 0049W d0 du Apr PWd* is bue and carrot
i . - �a
P 3-�, 04 (0
[6.Other
awOnly. Do sat�in dGis Wv%to be roapleted by city or town official
Town: Permit/License#
Authority(cirde one):
dofHealtb2.BunftgDgWtment 3.Citylrowa Clerk 4. 1 Inspector 5.Plumbing inspector
Person: Phone#:
3/.22A2012 10 : 41 : 19 AM 8935 02/02
DATE(MM/DD/YYY)
CERTIFICATE OF LIABILITY INSURANCE 03/21/2012
THIS CEBTIFICATE IS ISSUED AS A MATTER OF INFORMATION OILY AND CONFERS 80 RIGHTS UPON TBB CERTIFICATE BOLDER. TIES CERTIFICATE
DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER Tee COVERAGE APPORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF
INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(G), AUTHOR12M MIESBZTATIVE OR PRODUCER, AND THE
CERTIFICATE BOLDER.
n[PORTANT: if the certificate holder is an ADDITIONAL INSURED, the policy(ies) must he endorsed. If SUBROGATION IS WAIVED, subjeCt
to the,terms and conditions.of the policy, certain policies may require an endorsement. A statement on-this certificate does not
confer rights to the certificate holder in lieu of such endorsement(s).
PRDDUCER t�raer
Rogers & Gray Insurance Agency gym:
PEDRE
Inc (A/C.Va. n.t): wD.Ba):
E-Eun.
Po Box 1601 XDDDJM'
PRODUCER
South Dennis, MA 02660 `USTNmR 10.
INSURED(C) "FORDING CeDERAGE EOIC B
Frontier Energy Solutions Inc mmum A,A.I.M. Mutual Insurance Co 33758
I6DD8 B:
502 Harwich Road mSUMM E:
Brewster, 14A 02631 INSURER D:
IRSURM X.-
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS is To CERTIFY LSAT Mo PeL=M3 of IOSORN=LISTED BELOW HAVE Rww Issm TO TEE INSURED> ABOVE FOR THE POLICY FERIOD I<DDCa=.
BO.1wramP3NDIl1.ANY NEa vMURMT, T OR cOI01YTDH OF ENY corms OR omm 00=3=T aM RHSPEL•P TO WarCH THIS CEWEM=s MY BE ISSUED OR ICY
PEMM, -me X13172ANCE Arromw BY IBM POLDCffi ESSCQ1®HBBSni Is SUBJECT TO ALL TEE M@6, SNCLOSDDNS AND CONDITIONS OP SVCR POL=M. LUMTS BROWN
NZY I=Eta Isum m BY PAW MILTM.
Im POLICY NUMOM POLICY EPP POLICY Ew L�
u+ TEE OF INSURANCE CDV+A/"M ow"ft )
GENERAL LIMXLI1R EAm DCCBRANCE i
❑COITDRCIAL GENERAL LIABILITY DRf.DE TO RC•TED s
PRDRSEB(EA.•—)
❑ PENS01"c av ImRE 4;
❑ GEOaRu AGGRCGATE $
GED'L AGGREGATE LIen APPLIES ER:
❑eacuz ❑PR -❑— =IS-COW/OP AEG
i
AUTOTABXLS LXRB311W COKRMD SnMLE.I.I*V
(ea acciieat? e
❑ARE I.UTO
BUDILT Imp to—DttsmE G
❑ALL OWED AUTOS '
❑scEmloaBD Aoros
DOUBLY meStfflPCl aaclemq $
PROPERTY WIMSE.
f
❑.TREE ABIOS (Der.mtamt)
11902-01mED AFROS C .
❑ e
1101HREIZA LIAR ❑OCCUR EACH OCCOIIDgCE. /
❑EYCBS LIAR CLAMS MANE ABiPEOR 6
❑DEDUCTIBLE C
❑REIERIOA E i
WORZZRr COMMSATION ®
Am EM¢fOYBES LIABILM 1°a Lma m
M PROPRIETOR/PARTHER3/ E.L. Sam ACCIDENT D 1,000,000
A EFQ;C WE OFFICERS ARe
incl ® excl .6015315012012 03/14/2012 03/14/2013 E.L. DISEASE-POLICE LnIIT a 1,000,000
,
E.L. DISEASE,-EA CKPLU 6 f 1,000,000
cmumis i visawTI®cr OPP8 izan OR LOcanDIS:
FRANCIS SHEEHAN IS NOT COVERED BY THE WORKERS' COMPENSATION POLICY
WORKERS' COMPENSATION COVERAGE APPLIES TO MASSACHUSETTS EMPLOYEES ONLY
CERTIFICATE HOLDER CANCELLATION
THIESCH ENGINEERING INC
seomro ANY of INS aBovN DEscRISEU POLICIES BE caacELrED escoss TSe
ffiERE'1TON DAM THERIDOF, NOTE WILL BE DELIVEMM IN ACCORDANCE WM M6
195 FRANCIS AVENUE POLICY PROVISIONS.
CRANSTON, RI 02910 ��
5321
f
1
OWNER AUTHORIZATION FORM
(Owner's Name)
owner of the property located at
1�23-o �yi '
(Property Address) '
w err. 5 fa b'/e-
(Property Address) '
hereby authorizeFC(M4'1
(Subcontractor) '
an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building
permit and to perform work on my property. '
Dwner's Signature
OCT 2 3 2012
Date I
Massachusetts-Department of Public Safety "estr►
'Board'"of Building Regulations and Standards `- •cted To:CSSL-4c Insulation Contractor
R
Construction Supervisor Speeialn
License`CSSL 10594t r "
-
BIEWSter']�
j Failure to possess a currea edition of the Massachusetts
J.C.•• ... os iA`• a
Gommissiober Expiration : =s state Building Code is cause for revocation of this license.
02/17/2016
For DPS ticensiiig information visit www.Nass.Gov/DPS
/BelNo�G/l�iu:rcc/uvells
Office of Consumer Afrairsane»eo�rtaeti&-Busidew.-Regnlatioa-, =' License or registration valid forindividnl use only
- ME IMPROVEMEWT'CONTRACTOR ` . before the expiration date. ]iffound-return.to:
:r
. Regulation
registration: .160854 Type:' - Office of Consumer Affairs and<B.nsiness
- iration:,:._902-014. LLC 10 Yark Plaza-Suite 5170
Boston,MA 02116
FRONTIER ENERGYSOL[fl IONS:
:...FRANCIS -
:502 HARWICH RD. /�-�
BREWSTER,MA 026SI Undersecretary!-
rY A- of 'lid ithoat signature
• I
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Map Parcel_ Permit#
r
i
,.-Health Division C ✓ 4 Date Issued 2-_l " 9�
Conservation DivisionAft Z / Z 1 L-- _ F_ee C�n2S 00
Y%J? EP T IC SYS d E00 c„► �� BE
Tax Collector
���` NSTALLE® IN CMveLaAN`.E
_� WITH TITLE, 0/Treasurer -- — 'y ENVIR q P 7,7 ,� .
nnmg t. Mm
Date- )e#ini 4P—Plan Approved by Planning Board 1
6-14istoric-OKI -� Ae,-4,� Preservation/Hyannis
Project Street Address 1l3 0 /7ar S
Village Ag,e4. "
Owner Address
Telephone (J-0 F- 3/a
Permit Request /o Roxgv, • 9' le lcP. d9eclr w.`��i sQ�Ze sae 4ck u.rl�o
kpv
eltSquare feet: 1 st floor:existing_ proposed 2nd floor: existing proposed Total new
Estimated Protect Cost 00 Zoning District Flood Plain Groundwater Overlay
Construction Type dec
Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation.
Dwelling Type: Single Family 0/' Two Family ❑ Multi-Family(#units) �/
Age of Existing Structure Historic House: Ell Yes ❑No On Old King's Highway: Yes ❑No
asement 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
bw.��►e�Heat Type and Fuel: ❑Gas ❑Oil ❑ Electric ❑Other
Central Air: ❑Yes ❑No Fireplaces: Existing oil a New Existing wood/coal stove: ❑Yes SIG
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
BUILDER INFORMATION
Name e.e Telephone Number 6-60
Address �-19 --�el7eze,-e License# 301/
O 20,X Home Improvement Contractor#
Worker's Compensation#
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO
SIGNATURE DATE F 6 17, 1999
FOR OFFICIAL USE ONLY
PERMIT NO.
DATE ISSUED » /
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
DATE OF INSPECTIO '
FOUNDATION
"
FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH - FINAL
PLUMBING: ROUGH- FINAL
C -
GAS: ROUGH FINAL
y � � J V ' t + • • . J••
IlY{� FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO. a
i -
` Application to ... t ,
' g g Old.Kin 's Highway Regional Historic District Committee 1 9 9 9 19
in the Town of Barnstable for a
CERTIFICATE OF APPROPRIATENESS
Application is hereby made, iri triplicate, for the issuance of a Certificate bf 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 Q
Indicate type of building: ❑ House ❑ Garage ❑ Commercial tether�/� Grer4
2 Exterior Painting: ❑
3. Signs or 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 l/ /3 99
ADDRESS OF PROPOSED WORK ��30 a�`� -1 Gr/ '4".' . ASSESSORS MAP NO.
OWNER ASSESSORS LOT NO. 0
HOME ADDRESS (a Gov e ) TEL. NO.��aS� 312-377,�
FULL NAMES AND ADDRESSES OF ABUTTING,OWNERS. Include name of adjacent property owners across_ any public
street or way. (Attach additional sheet if necessary).
T
AGENT OR CONTRACTOR Cu% 17W TEL NO.dZ2 8) f-w g 4L=
ADDRESS AVa- ' /�D, ,BoX i`?a esl�e�.s �l.'l/ 0 2l f�-000/ o -r
o
DETAILED DESCRIPTION OF PROPOSED WORK: Give all particulars of work to be done(see No.S.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). `
/�e•drev� QnaP C ;G�ecr� �.—'C h store. s ze mil ,,d
�ieecP sy� li..`cl he cases
F�DSigned - �c�— Q� -. •�_• ��
Own er-Con tractor-Agent
Space below line for Committee use. ���� � � �iGdl�o_ / •T 1 ISt2[.1
I !nil I
aDate 4'' i' 's j;7he cafe is hereby Date "� -`3
G, 9 6L=�
l,. Ti
Approved ~❑ IMPORTANT: If Certificate is approved,approval is subject to the 10 day a eal period
provided in the Act.
lq?
�S ti/ele.� �la.�elrs �aRl/r°//
ke
If
�/• �a��.� .�.9 o z C G•�!/3�
z 7- g3 .�ccks�
-
'�
i
Town of Barnstable
Old King's Highway Historic District Committee
/J SPEC SHEET
FOUNDATION
SIDING TYPE COLOR
CHIMNEY TYPE /V /151 COLOR
ROOF MATERIAL COLOR
PITCH
WINDOWS �/`l COLOR SIZE
TRIM COLOR
DOORS COLORS
SHUTTERS j� COLORS
GUTTERS COLORS
DECKS -seP a.23�17ea MATERIALS �eQfu�e �2ea.��� sy/11
GARAGE DOORS COLORS
SKYLIGHTS /// SIZE COLORS
SIGNS :'G' COLORS
FENCE /4%4 COLOR
NOTES: Fill out completely, including measurements and materials/colors to be used. Four copies of this
form are required for submittal of an application, along with Four copies of the plot plan, landscape
plan and elevation plans, when applicable.
SPECSHT
Revised 11198
i
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9.8 AC TOTAL '
o
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1Kiza.o e. Ole &17L e vet
The rfown of Barnstable
• a�ariarw� •
Department of Health Safety and Environmental Services
Building Division
367 Main Street,Hyannis MA 02601
Office: 508-862-4038 Ralph Crossen
Fax: 508-790-6230 Building'Commissioner
Permit no.
Date
AFFIDAVIT
HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion,
improvement,removal,demolition, or construction of an addition to any pre-existing owner-occupied
building containing at least one but not more than four dwelling units or to structures which are adjacent to
such residence or building be done by registered contractors,with certain exceptions,along with other
requirements.
Type of Work: Estimated Cost LL6- 00
Address of Work: /&Q'0
Owner's Name: /4-7
Date of Application: 1--e-6 /7, 1949
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job Under$1,000
Building not owner-occupied
❑Owner pulling own permit
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A.
SIGNED UNDER PENALTIES OF PERIURY
I hereby apply for a permit as the agent of the owner.
e� �7 , /9W �u� Boil�Je2 7 7e, 10ex;1
Date Contractor Name Registration No.
OR
Date Owner's Name
q:forms:Affidav
M_ k- _ The Commonwealth of Massachusetts
± — Department of Industrial Accidents
Office nf/eyesaffsaas
EEL
600 Washington Street
i� Boston Mass. 02111
Workers' Compensation Insurance Affidavit
name: C ce-�g A-All ee
7�es, ,2 9 E6ene i e2 X!X,
location: /-,7 a.% : /4 O. ,A,*, ±er r
cityQicrs/ phone
❑ I am a homeowner performing all work myself.
21-1 am a sole proprietor and have no one working in any capacity
❑ lam an employer providing workers- compensation for my employees working on this job.
compnnv name: .
address:
city- phone#:
insurance co. policv#
❑ I am sole proprietor eneral contractor. or homeowner(circle one)and have hired the contractors listed below who
have
the follmOng workers' compensation polices:
comvanv name:
address:
. .:...:...
city phone#-
insarnnce ca. ...:.:.: oiiiv#.. .. ,.;.::::::•:::::>::<:>::>:.»:z<:•;;»::.
cam panv name- ..::::.: .:.:::::::s:;.;;::::•::.;..,...::.
address:
city- phone#: ..: ..: :..:...:.::::;,:.....::;:•;..
Insurance co. policv# ::<z::.:.<;::»:>:::;:.::::::: ::::;::.;;;.:.:..:::.,;:.;;•::::....:,::
//%G//
Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a ate up to S 1.500.00 and/or
one vears'imprisonment as well as civil penalties in the fours of a STOP WORK ORDER and a ate of S100.00 a day against me. I understand that a
copy of this statement may be forwarded to the OMce of Investigations of the DIA for coverage verification
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct
Signature � Date �� /), /QA, _
J
Print name Phone#125`08)
fcontactper3on:
use only do not write in this area to be completed by city or town otIIcial
own: permit/license# ❑Building Department
❑Licensing Board
kiflmmediate mponse is required ❑Selectmen's Ottice
❑Health Department
phone#; ❑Other
(mvea 9i95 P1A1
Information and Instructions
Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their
employees. As quoted from the "law", an employee is defined as every person in the service of another under any co=-.-
of hire, express or implied, oral or written.
i
An employer is defined as an individual, partnership, association, corporation or other le al entity, or an two or more of
P P� ny rP g Y
the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver c:
trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a
dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of
another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or
building appurtenant thereto shall not because of such employment be deemed to be an employer.
MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renewa
of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has
not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the
commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until
acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting
authority.
WX
Applicants
Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and
supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may be
submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and
date the affidavit. 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.
/ ���i,���/ / �i.!/i,! /���/ /������� ��ii.�i,�iii,. W
City or Towns
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the
affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please
be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned io
the Department by mail or FAX unless other arrangements have been made.
The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions.
please do not hesitate to give us a call.
The Department's address,telephone and fax number-
The Commonwealth Of Massachusetts
Department of Industrial Accidents
oQlca of imlesugatloas
600 Washington Street
Boston'Ma. 02111 j
fax#: (617) 727-7749 '
phone#: (617) 7274900 exL 406, 409 or 375
�12C C/Jd977/I➢tODtIdCRU./L d�ai��aC�ZLWe� '.
AN
s.
DEPARTMENT OF PUBLIC SAFETY
CONSTRUCTION'�SUPERVISOR LICENSE ;
NumDe4 = '.Expires:
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PO BOX'4", ;c,-
MARSTONS MILLS, MA 02648
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