HomeMy WebLinkAbout0028 MINTON LANE �� ��`��
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OX, forld NO. 152 1/3 ORA
ESSE E 10%
�"M Town of Barnstable _ Building
? BAMBrABM Post This Card So That it is Visible From the Street-Approved Plans Must be Retained on Job and this Card Must be Kept
DUO& Posted Until Final Inspection Has Been Made.1639.
Permit
+ Where a Certificate of Occupancy is Required,such Building shall Not be Occupied until a Final Inspection has been made.
Permit No. B-19-3945 Applicant Name: Roland Langevin Approvals
Date Issued: 11/22/2019 Current Use: Structure
Permit Type: Building-Insulation- Residential~ Expiration Date: 05/22/2020 Foundation:
Location: 28 MINTON LANE,WEST BARNSTABLE Map/Lot: 174-031 Zoning District: RF Sheathing:
Owner on Record: MEYER, REBECCA E Contractor Name: INSULATE 2 SAVE INC. Framing: 1
Address: 28 MINTON LANE Contractor License: 180747 2
WEST BARNSTABLE, MA 02668 Est. Project Cost: $3,946.00 Chimney:
Description: attic damming, R-30 cellulose to attic flat, rigid board to kneewall, Permit Fee: $85.00
R-14 cellulose to kneewall floor,seal and insulate and weatherstrip Insulation:
kneewall hatch,ventilation chutes,soffit vents, home air Fee Paid:; $85.00 Final:
sealing,rigid board to common walls, R14 cellulose to overhang, Date: r 11/22/2019
rigid board to overhang
Plumbing/Gas
Project Review Req: Rough Plumbing:
i- ----------�.�.� NBuilding Official Final Plumbing:
This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance.
All work authorized by this permit shall conform to the approved application and the'approved construction documents for which this permit has been granted. Rough Gas:
All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes.
This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the Final Gas:
work until the completion of the same.
Electrical
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this,permit.
Service:
Minimum of Five Call Inspections Required for All Construction Work:
1.Foundation or Footing _ Rough:
2.Sheathing Inspection
3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final:
4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection
5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough:
6.Insulation
7.Final Inspection before Occupancy Low Voltage Final:
Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health
Work shall not proceed until the Inspector has approved the various stages of construction.
Final:
"Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A).
Fire Department
Building plans are to be available on site �p
p : Final:
All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT
S�
Application Nimmb ...-.l. '... . ,. ... ......
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MA88. Permit Fee........................................Otbea Fee.................:......
►�� //0
TotalFee Paid................h........................ .......................
Permit Approval by .oa..�l/.Q-a. — . e
TOWN OF BARNSTABLE ---•••••••••-• •--••• ••
BUILDING PERMIT
Map................. ............Pffirr1........ .. .. .....................
APPLICATION
Sections -Owner's Information-and Project Location--
Project Address a �3 M;n pan L c.n vZla (�G f.,s a h I e
gal Addr�ess, 4,g M'r.}��• L��,e --
C�rty� Stated //1/1 A 7�p l7 a•
Owners-Cell#--�-C-��- 8 ��.-`T°I ! S Frmaal �e SDo��(�nn�� , •
Sion.2—.Use-of-Structure
Use Group ❑ Commercial Structure over 35,000 cubic feet
❑ Commercial Structure under 35,000 cubic feet
TOWN 0 BABNS i'ASi-t
Single/Two Family Dwelling
S ctioa 3—fie-off P-ermit
❑ New Construction ❑ Move/Relocate ❑ Accessory Structure ❑ Change of use
❑ Demo/(enure structure) ❑ Finish Basement ❑ Family/Amnesty ❑ Fire Alarm
Rebuild Deek- Apartment ❑ Sprinkler System
❑ Addition ❑ Retaining wall ❑ Solar
❑ Renovation ❑ Pool ❑ Insulation
Other-Specify
tSecbbiiQ 4=Wert Description
e-cK fib bc,clt „tea n
Tito m+dstmh 21W201 S
f
Application Number.....................................................
Section 5—Detail
LCostof P-roposed.Construction� 3,C .(IO Square Footage of Project
Age of Structure Dig Safe Number
# Of Bedrooms Existing Total#Of Bedrooms(proposed)
110 MPH Wind Zone Compliance Method, ❑ MA Checklist ❑ WFCM Checklist ❑ Design
Section 6—Project Specifics
❑ Wiring ❑ Oil Tank Storage ❑ Smoke Detectors-
❑ Plumbing ❑ Gas . .❑ Fire Suppression
❑ Heating System ❑ Masonry Chimney ❑Add/relocate bedroom
Water supply ❑ Public ❑ Private
J .
Sewage Disposal ❑ Municipal "❑ On Site
Historic District ❑ Hyannis Historic District ❑ Old Kings Highway
Debris Disposal Facility: I an using a crane ❑ Yes ❑ No
Section 7—Flood Zone
Flood Zone Designation
Within or adjacent to a wetland, coastal bank? Yes ❑ No ❑
Section 8—Zoning Information
Zoning District Proposed Use Lot Area Sq.Ft.
Total Frontage Percentage of Lot Coverage #of Dwelling Units (on site)
Setbacks Front Yard Required Proposed
Rear Yard Required Proposed
Side Yard Required Proposed
Has this property had relief from the Zoning Board in the past? ❑ Yes ❑ No
Last undated:2/9/2019
Application Number...........................................
Section 9—.Construction Supervisor
' Name Telephone Number
Address City State zip
License Number License Type Expiration Date
Contractors Email Cell#
I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780
CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and
€ documentation b 780 CMR and the Town of Barnstable.Attach a
required y copy of your license.
Signature Date
Section-10 —Home Improvement Contractor
Name Telephone Number
Address City State zip
Registration Number Expiration Date
I understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780
CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and
documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your H.LC...
Signature .Date
__.._ S�ec�tiWn_1:1=-Home-Owners- !'censer me pho
Home-Owners Name: R e-6P_c-c_G Mr_,�
Telephone Number 9 095 -81 _Z11 �; Gell*or-Work-Number
I understand my responsibilities under the rules and regulations for Licensed Contraction Supervisor in accordance with 780
CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspection and
documentation required by 780 CMR and the Town of Barnstable.
s —gnature'i� Date 10 13
SIG N �TURE)
Si Dat � 21
iBH Name e-6 cc,-, N e- e�r T-e}ephone_N_. be 1 U6S-
E permit:�o:
T n.d......3..r�.3.�/nnnt0
Section 12-Department Sign-Offs _
Health Department ® Zoning Board(if required) ❑
Historic District ❑ Site Plan Review Of required) ❑
Fire Department ❑
Conservation ❑ j
For commercial work,please take your plans directly to the fire department for approvak
Section 13-Owner's Authorization
I, jkf_UC_C Mc v. as Owner of the-subject property hereby
authorize S P-4� M._ y e_c' to act on my behalf, in all
matters relative to work authorized by this building permit application for:
�.$ r+n,• •k►r L cox4 W esh Awn s i-s t le- .4
(Address of job)
Signature of��'er' date
R g_6cccv,
Print Name
Last uadatc&2/9/2018
Town of Barnstable
.. Building
Post This Card So That it is Visible'From the Street-Approved Plans Must be Retained on Job and thisCard Must be Kept
MAS& Posted•UntilFinal Inspection Has Been Made. Permit
i6sv►`b$ `1
Where a'Ceitificate of Occupancy is Required,such Building shall Not be Occupied until a Final Inspection has been made. er
Permit No. B-18-2449 Applicant Name: MEYER, REBECCA E Approvals
Date Issued: 08/13/2018 Current Use: Structure
Permit Type: Building-Deck Expiration Date: 02/13/2019 Foundation:
Location: 28 MINTON LANE,WEST BARNSTABLE Map/Lot_ 174-031 Zoning District: RF Sheathing:
Owner on Record: MEYER,REBECCA E w Contractor Name: Framing: 1
Address: 28 MINTON LANE Contractor License:
� 2
WEST BARNSTABLE, MA 02668 j - Est. Project Cost: $3,000.00 Chimney
:
Description: Building a 16x12 Deck to backyard and Installing Slider to access ' Permit Fee: $ 110.00
Insulation:
Deck. i Fee Paid:r $110.00
Project Review Req: + Date:,f 8/13/2018 Final:
I Plumbing/Gas
y Rough Plumbing:
Building Official
Final Plumbing:
Rough Gas:
This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance.
All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. Final Gas:
All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws.and codes.
This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open-for public inspectiohn for the entire duration of the
i
work until the completion of the same. Electrical
Service:
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit.
Minimum of Five Call Inspections Required for All Construction Work:, Rough:
1.Foundation or Footing l ""
j 2.Sheathing Inspection Final:
3.All Fireplaces must be inspected at the throat level before firest flue lining is installed
4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Low Voltage Rough:
5.Prior to Covering Structural Members(Frame Inspection)
6.Insulation Low Voltage Final:
7.Final Inspection before Occupancy Health
Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Final:
Work shall not proceed until the Inspector has approved the various stages of construction.
"Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department
Final:
Building plans are to be available on site
All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT
LOCATION SEWAGE PERMIT NO.
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VILLAGE —'
q= 04 03i
I N S Tj LLE 'S NA i ADDRESS
67)A
B U I L D E R OR OWNER
DATE PERMIT ISSUED
9
DATE COMPLIANCE ISSUED
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` 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 Bu is pis ness/Organization/Individual): Rom.b,_GCc,� �`1'� des eY'
f ddr- ss:
O 66 Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g, ❑Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers'comp.insurance comp.insurance.:
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.X I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself [No workers'comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees. [No workers' 13 K0ther Z e G)�,
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 thepolicy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certi6um4er the pains and penalties of perjury that the information provided ove is true andcorrect.
Si afore:' Date: l t b
(:Phope-#AQg' Q 2—-)
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#:
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."
i
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 insurannce 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 permittlicense applications in any given year,need only submit one affidavit indicating current
i 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-MASSAFE
Revised 4-24-07 Fax#617-727-7749
www.mass.gov/dia
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,• �> ;' TOWN OF BARNSTABLE permit No. _2�115,.__-------
t »n.0 Building Inspector cash ---_----
�ay
'"'' OCCUPANCY PERM17 Bond _—X__�� -
Issued_to GreP.Slbrler Corp. w Address
Loft 24, 28 Mir OnLane; Centerville
Wiring Inspector � � Inspection date
Plumbing Inspector '��, 5 �� Inspection date
Gas Inspector INn", ��, ,� Inspection date
XEngineering Department Inspection date�� �
Board of Health .G 1 Inspection date
THIS PERMIT WILL NOT BE VALID,-AND'THE BUILDING SHALL NOT BE OCCUPIED UNTIL
SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN
REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE
BUIL/DING CODE.
Building Inspector
FROM
TOWN OF BARNSTABLE.
BUILDING DEPARTMENT
Mr. Francis iahteine 887 MAIN STREET HYANNIS, MA . i
Tbwn,clerk IJ�
" 4R'........h'(tP•MAiMWvI� I Phone: 7754120
SUBJECT:
FOLD HERE
DATE
December 20 1984 MESSAGE
Work have been ccr>�leted.under Permits Number 27028 & 27115,
. ♦ ��?Y'hnb aa iF ye+•I'=w,we•+_vw'.{�t M�K i•1N w'+l�,YY,sTV y>•;MArV aY'.sKadw�`.. VI�. Yi Sl�fik�`�R ♦!f r1w
(Greenbri -Ger »-Please release Bonds
+F'R`flx4wv�,.il�►�F••4.:,••6+-'F.W�.`.nee»M•Nb• eke•F.!•►w.....ai'a.wPU+..►.+....►wra.aa.•.�- c s s'f.o•v,
i S GNED �-
DATE +
REPLY
4 r
�• - y . SIGNED
Ne7-RMI' RECIPIENT: RETAIN WHITE COPY,RETURN PINK COPY
. PRINTED IN U.S.A.
SENDER: SNAP OUT YELLOW COPY ONLY.SEND WHITE AND PINK COPIES WITH CARBON INTACT.
001h
Assessor's map and 16t number ............................................
THE
SEPTIC SYSTEM MUST
Sewage Permit number . ........................... INSTALLED IN COMPLIA,
AUSTAXLE,
House number ........................!�.ga..................................... WITH T�7',, NAG&
039.
TOWN OF BARNSTABLE
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO .............................. ........... ...........
...............
TYPE OF CONSTRUCTION .................................................... ...�......F .................................
............ .......�r...........19..�.y
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location ... ........ .............................................................................
ProposedUse ............................ ....... ...........................................................................................................
Zoning' District ................................I ......................................Fire District ...................... .........D
............
Name of Owner ................. ....C(V/K�7..Address ........................ ........�zo- -
...................
Name of Builder ............................ ......................Address .................................................................
Nameof Architect ........................ .........................................Address ..............................................
Numberof Rooms .....................V.........................................Foundation ......................
Exterior - / " .. ..............Roofing ...--Cf.................. ... .... . . .. ... ...........
Floors .................... ....................Interior ..........................e�;.4:.......;...(... ..................
Heating ........................... ........... ............Plumbing ............................... 7.`!�'.(..........I.................
Fireplace ..................................... ............................................Approximate Cost ............................(.......................................
Definitive Plan Approved by Planning Board ----------1K�--- ------------19--aq Area ...... .... All
Diagram of Lot and Building with Dimensions Fee ................. ...f... .... ...........
SUBJECT TO APPROVAL OF BOARD OF HEALTH
i� .
76 e
Z17-
..........
C...................../,�
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the Rules and Regulations of the Town of Bornstobl r garding the abovge
construction.
Name ..................................................................................
Construction Supervisor's License .......d-
...................
A
REENBRIER CORP.
AkNa 21115...... Permit for ...A.§P?rx...............
'.....Single..Fand.1v..Dwe.11iPg
Single........... ... Dwelling
.....................
Location X?Pt.24/....AJAXIWA..Lang.............
................ Q ...............
Owner ......Greenbrier-COr-ID...........................
Type of. Construction .....EraWe..........................
................................................................................
Plot ........................ Lot .................................
Permit Granted ......October...1.8............19 84
...........
Date of Inspection ...... .......... ...........19
Date Complete .... 19...............
.....
Assessor's map,and; lot number ............................................ cF THE t0�
Sewage Permit number ,............................................
AU S'TOD
House number ��` �� *H M6 a $......................................................................... .
t 39.
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i
TOWN . OF BARNSTABLE
BUILDING INSPECTOR_
APPLICATION °FOR PERMIT TO .................... ....`...... 1� .5. . .............1 `:.. ...... �:..........
TYPE OF CONSTRUCTION ........
............................... ..................... e.(.......F .................................
............ ..............19.. .�
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the followinginformation:
Location ... - .... .. ........��l.�l` d\.�?nQs., .: .�..t�.�P..................................... ...................................
� .04Proposed Use ............................. ..........................................................................................................
Zoning District ................................ .......!.....................Fire District ..................... .. ..�................................ .. r
Name of Owner ................. � `` L 1....1... Address ....................... )`... ........ .... ..............
Nameof Builder ....................... ...............Address .........................................................4..........................
Nameof Architect ......................//...........................................Address ....................................................................................
Number of Rooms .....................6........................................Foundation ..............:......................................:
Exterior ................ /.....C...�^......... ... S.`....5...............Roofing ..................... s 3 ............
%�.. .... .... -.... .
Floors ......................... ................� .....................Interior ......................... .......`�................. �.
, ! ... �. .... ....................
xe
Heating :.....� .S.......... Gf//9............Plumbing ..............................2... !............................
�( 6 0 U 0
Fireplace ..................................................................................Approximate. Cost .......................... r......................................
Definitive Plan Approved by Planning Board -------- 19__ `_I. Area ..........................................
Diagram of Lot and Building with Dimensions Fee ..............................................
SUBJECT TO APPROVAL OF BOARD OF HEALTH
c(Kz Z
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstabl r garding the above
construction.
Name ............. ............
.... ........... .... ........ ........
• Construction Supervisor's License ....... ........................,...
GREENBRIER CORP. A=174-2
No 27115...... Permit for ....V.i.§.tO ...............
' i
.........S agle-kdT 2y...I?iae.117LT u.....................
Location .....Wt..24.,.....2a.i,,ji tQn..T aue........
................. . ....................................
Owner ......G QeribX'.],Qx..GQKPA.............:............
Type of. Construction ...Frame...........................
........................................... ,
Plot ...:......................... Lot ................................
Permit Granted ....PPP? ...........19 84
Date of Inspection ....................................19
Date Completed ...............:.......................19
}
l -
HE
ti Town of Barnstable
Fay)ires 6 months from issue date
• BARNSPABLE,
MASS. Regulatory Services Fee
�A. 1639• ,0� Thomas F.,Geilcr,Dircct.ol-
TfD MP't h \
Building Divisioh Q \O._
Tom Perry, Building CorniniSsionel' 4k
Office: 508-862-4038
200 Main Strect, Hyannis,MA 02601
Fax: 508-790-6230
EXPRESS PE) 41T APPLICATION - RESIDENTIAL ONLY
Not Paud mifhout Red X-Press Imprint
Map/parcel Number_ 1 7 q
Property Address :56,4 , 1 A)T�)N ,
Residential Value of Work 1 D�,�o Minimum fee of$25.00 for work under$6000.00
Owner's Name&Address.
A8
Contractor's Name Telephone Number �S
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
lkvorkman's Compensation Insurance
Check one:
❑ I am a sole proprietor Xq® ES PERMIT
T am the Homeowner �'"
I have Worker's Compensation Insurance
FEB - 8 2008
Insurance Company Name 444 TOIAINM P RQRNSTABLE
Worklnan's Comp. Policy# � �.E� rr
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
❑ Re-roof(stripping old shingles) All construction debris will be ta]cen to
❑Re-roof(not stripping. Going over existing layers of rood
❑ Re-side
Replacement Windows. U-Value 04Q' (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. Ec '01 'Yd 9— } ;
Hol Impr vement Contractors License is required.
ignature ; `1.�.`:t.nl; _ .Jl
:Foms:expmtrg
.vise063004
i
Client#:47298 CAPIHOM
ACORD,. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
PaODUCER 12/26/2007
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Rogers 8r Gray Ins.-So. Dennis ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
434 Route 134 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
P.O.Box 1601 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
South Dennis,MA 02660-1601 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURERA: NGM Insurance Company
Capizzi Home Improvement, Inc. INSURER B: American Home Assurance
Capizzi Enterprises, Inc.
1645 Newtown Road INSURER C:
Cotuit,MA 02635 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
LTR NS TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION
R
DATE MM/DD/YY DATE MM/DD/YY LIMITS
A GENERAL LIABILITY MP010707 06/08/07 06/08/08 EACH OCCURRENCE $1 000 000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED-PREMISES(Ea=urrencaj $500 QQQ
CLAIMS MADE D OCCUR MED EXP(Any one person) $1 Q QQQ
PERSONAL&ADV INJURY $1 QQQ QQQ
GENERAL AGGREGATE $'t QQQ QQQ
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2 000 000
POLICY LOC
PRO-
JECT
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
ANY AUTO (Ea accident) $
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) $
HIRED AUTOS
BODILY INJURY $
NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE71 $
(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 $ $
B WORKERS COMPENSATION AND WC1764953 12/25/07 12/25/08 WC STATU- OTH-
EMPLOYERS'LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT s500,000
OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $500,000
If yes,describe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT s500,000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Corporate officers are included in Workers Compensation coverage.
CERTIFICATE HOLDER CANCELLATION
t SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
Town of Barnstable DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1n DAYS WRITTEN
200 Main Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SHALL
Hyannis,MA 02601 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
ACORD 25(2001/08)1 of 2 #S33206/M33205 KW 0 ACORD CORPORATION 1988
J/LC &1-27 747 7 01zI(O V11 O1✓11&j 1Q.Cl7.WdC&
=- Board of Building Regulations and Standards License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Board of Building Regulations and Standards
�. Registration: 100740 One Ashburton Place Rm 1301
Expiration: 6/23/2008 Boston,Ma.02108
Type: Supplement Card
CAPIZZI HOME IMPROVEMENT, I
VARY GUSTAFSON
1645 Newton Rd.
Cotuit,MA 02635 Administrator t valid with t sig ture
r
Board of Building Regula ions and Standards
One Ashburton Place - Room 'l301
Boston. Massachusetts 02108
Home Improvement Contractor.Registration
Registration: 100740
Type: Supplement Card
Expiration: 6/23/2008
CAPIZZI HOME IMPROVEMENT, INC..
GARY GUSTAFSON
1645 Newton Rd.
COtuit, MA 02635 Update Address and return card.Mark reason for change.
Address Renewal Employment Lost Card
J� •t�a77v77zo7w�Co� of'�,1i .i
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 74640
Expiration: 11/29/2008 Tr# 6430
Restriction: 00
GARY GUSTAFSON
8 SHORT WAY
SANDWICH,MA 02563 Commissioner
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):
Address:
o
City/State/Zip: �e�GLtiY Phone.#:
Are you an employer?Check the appropriate bog: Type of project(required):
1 .I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
workingfor me in an capacity. employees and have workers'
Y P tY• $ 9. ❑ Building addition
[No workers'comp.-insurance comp. insurance.
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their l l.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
1contractors 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. �Q
Insurance Company Name: // �>�nS
Policy#or Self-ins. Lic.#: ! DSO `�—2-31 Expiration Date: d
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 tip to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pain s-andpenalties ofperjury that the information provided above is true and correct
Si ature: Date: D _
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#:
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."
I
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."
i
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 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.
'Me 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
Revised 11-22-06 Fax# 617-727-7749
www.mass.govldia
CAP
iM--
HOME IMPROVEMENT
I, Gary Gustafson,Production Manager of Capizzi Home Improvement,Inc.,hereby
authorize Jan Donnelly to sign on my behalf for permit applications filed through the
town.
I
Signed:
ln
0 Gary Gustksdi{ d
/flan Donnelly Date
1645 Newtown Road, Cotuit, Massachusetts 02635 • Tel. (508) 428-9518 • Toll Free (800) 262-5060
Fax. (508) 428-1547 • Email: chi@capecod.net 4 Website: www.ca.pizzihome.com
j
Page 7 of 7
i CAPIZZI HOME IMPROVEMENT INC.
SPECIFICATIONS AND ESTIMATES
STATE OF MASSACHUSETTS
LETTER OF AUTHORIZATION TO APPLY FOR A BUILDING PERMIT
I, dl e✓1 e— t1v7G�i �`S 0 vv
2
OWN THE PROPERTY LOCATED AT i 1
IN MASSACHUSETTS.
I HAVE AUTHORIZED CAPIZZI HOME IMPROVEMENT TO ACT AS MY AGENT TO APPLY FOR
A BUILDING PERMIT IN ACCORDANCE WITH 780 CMR,THE MASSACHUSETTS STATE BUILDING
CODE.
I GIVE MY PERMISSION TO LESSEE
TO APPLY FOR A BUILDING PERMIT ACCORDANCE WITH 780 CMR, THE MASSACHUSETTS
STATE BUILDING CODE.
SIGNATURE OF OWNER:
OWNER'S ADDRESS:
OWNER'S TELEPHONE:
LESSEE'S SIGNATURE:
LESSEE'S ADDRESS:
LESSEE'S TELEPHONE:
APLLICANT'S SIGNATURE:
APPLICANT'S ADDRESS: 1645 Newtown Rd., Cotuit, MA 02635
APPLICANT'S TELEPHONE: 508-428-9518
RESPONSIBLE OFFICER:
RESPONSIBLE OFFICER ADDRESS:
RESPONSIBLE OFFICER TELEPHONE:
S.
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-a O44
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Assessor's office (1st floor):
Aisessor'q, map and lot number .1. ) f'..��3�... ... SEPTIC SYS E
Board of Health (3rd floor): tis II`- ' °����- I� !+ �. ..E
u 1?1 ru
Sewage Permit number ........... ::6.-7` �Q...... mil.✓cr SL),V —Cam ` i el s LE. S
Engineering Department (3rd floor): a E `,�;:-,'-NVjEN IND
House number ....................................................... �Q � TOWN REG
Definitive Plan Approved by Planning Board �j1=-------------19� _
APPLICATIONS PROCESSED 8:30-9:30 A.M, and 1:00-4:00 P.M. only 111
TOWN OF BARNSTABLE
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO (J1.4. ........A.;PP/TKO! . ...........................................................
TYPE OF CONSTRUCTION .......V(/Da �iE'4M�
...:All..&............................I q.."
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to' the w�g information: CLOT c�q)
Location .2 ?..!N1....�TO.!y......41A.NaEy..... . .. ..Q G.. ... �...I� l �SS.,........Q.7��
ProposedUse .....g►L��JA/.......RPPAo!?...................................................................:.........................................................
Zoning District ...... ....................................................Fire District .....X!+t+s.r..8.a e rl�
Name of Owner EP.MAWV...:.8..l.7c ...!kg dress .....Z$,WMAO":4...
Name of Builder 7W�.. a cST49j9RA&c !....CP......Address .//.70......I TS'....�►.!�/.�..A!.X, CA..�!...
��6 t7�' ..Z 3....,�t. ...S i.....So ..Q�da%
Name of Architect . .. . 1... ............................................Address ...........
Number of Rooms ......................................Foundation cm...... ` ....................................
Exterior .....V..l!.!... �i ...............................................R.00fing ......*4-17��'` ."..................................................
Floors / ...................................................Interior .....S "............. .................................................
Heating ....... i'`r�L ..................................Plumbing ........................
Fireplace ..... ... ............................................................. C�
Approximate Cost ..../... ...I............
Area .. ��...S. ...�..... i
Diagram of Lot and Building with Dimensions Fee
i
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the Rules and Regulations o"wnrnstlle?a.rcti.ng above
construction.
Name .... .. ..........
Construction Supervisor's Lic '.r�.��......
HUTCHINSON, EDWARD B.
,'(*No ..q!.N4..' Permit for ..Build..Addition
4••,.S• ngle.,Family,..Dwellin.g........•.
Location .....2$:..Mi ?tOn••LAne.......................
y ...............[!1 st..fax.>3s. le....................
Edward B. Hutchinson
Owner .............. ..........................................
Type of Construction .Frame
7 r,
Plot ............................ Lot ................................
Permit Granted .....April a3............19 88
Ddte of-Inspection .......... l9
.....................
' Date Completed ........................ 1.........19
196
f
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Assessor's office (1st-floor):
Aais'esser'vn�ap and lot number Ro7q- 61311 JYt ...... THE
...............
Board of Health (3rd floor): —
6-/- 7'fro
......I........... .. ....... 33AR39T&BLE,
Sewage Permit number .............. .....
MAO&
Engineering Department (3rd floor):
1639.
CP F- i
Housenumber .................................. . .. ......... ... a VA-4
Definitive Plan Approved by Planning Board ---44"-- -1--------------19 ?�-t),I�M�
(I
APPLICATIONS PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only
TOWN OF BARNSTABLE
BUILDING INSPECTOR
"Et
APPLICATION FOR PERMIT TO ........ .........
TYPE OF CONSTRUCTION
/-JE
...... ....................................................................................................................
............................I q..E'i7
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location ......
.............
Proposed, Use ..... I..,;.Al .......6zy.-PA l.............................................................................................................................
Zoning District ...... .... ....................................................Fire District .....
..............................................
Name of Owner
Name of Builder ......Address
Name of Architect ................... .................... .......................................Address
.... ........................le.�...
Number of Rooms ............... ..........................................Foundation i,.7A./.'
.. .............................................
4
Exterior ..... il/- '11 0- ........Roofing y i,)h ,,
..................................................... ...... ............................................ .. .. . .. .........
Floors //..... .....................................................................................................Interior or ..... . .... ..................................................
Heating .........................C.........................................................Plumbing ..................... ........................................................
Fireplace ...... ..............................................................Approximate Cost 4'>
......................
Area
Diagram of Lot and Buildi'ng with Dimensions Fee �0!...0///
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regairc(ing the above
construction.
Name .....................................................
. .........................
Construction Sup6rvisor's Lic6nse .......04
3.....f c.....
HUTCHINSON, EDWARD B. A=174-031
No-'! 31804 Build Addition
........... ..... Permit for ....................................
k Sinqle Family Dwelling...,..,,,,......Single .......................
Location -...2.8 Minton Lane
.............................................................
West Barnstable
...............................................................................
Owner ..E.dwa.rd....B......Hutchinson............
.. ....... .... .. . .... .. . .. ....... ....
Type of Con;tr-uction ............FKAMe.................
................ .................................................. ...........
Plot ............................ Lot ................................
April 13 88
Permit Grbn4ed ............................f...........19
Date of Inspection ....................................19
Date Completed ......................................19
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SHOWN .ON THIS. PLAN IS .. LOCATED' -
ft3'I', RED; RE018TERED , THE' GROUND -AS INDICATED AND
BURdEYOR "la,: t AR , ONFORMS TO THE ZONING: LAWS
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