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HomeMy WebLinkAbout0003 ALDEN WAY � cu� u�� �-- � _ �Z dow a of Barnstable *Permit Expires 6 months from issue A90; �iEn De artment Fee � g P �r EAMSTABLE, : 1 201� Brian Florence,CBO ���' �+�� g Building Commissioner 'OrFo Mpt A �� OOA treet,Hyannis,MA 02601 B www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X--Press Imprint Map/parcel Number 3©7 ��l Property Address _ �G r�G &�,4 Residential Value of Work$ a Uo Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address G—G c=—�v mot= /� L'ES'ff .33 r2� •v D G� -,G t✓ � � � Contractor's Name 6`j,4��k5 j�l4��i,'(� Telephone Number Home Improvement Contractor License#(if applicable) 1 79D.5rL3 Email: Construction Supervisor's License#(if applicable) CO 6 7.33 ❑Workman's Compensation Insurance Ch ck one: I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name ` Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows #of doors: ,. *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 re red. SIGNATURE: f QAWPFILESTORMSEXPRESS2017 The Com momveakh o,fMassadlrusettr Dee aranna o,f1i dassoial Accidera& - Off we we o,fTmw€iigadom 600 Washington,street Boston,MA 02111 wrov.masmgopldia Workers' CampensatianIusurance Affidavit B-m"lder-JCantractarsMecEt ;cians/Piu3nbers AmUcanf Infm maf an Please Print Legtibiy Nip . Addres ,ref /3 city/sta> r .Are you au employer?Check the appropriate bares:' Type of project(required}: 1.❑ I am a employer With. - - 4. ❑I am a general contractor and I 6..[—]New Construction employees(full andfor part-time).* have]Tired*e sub-contractors 2.( I am a sale proprietor orgartner- listed on the attached sheet'~ ?. ❑Remodeling / - These�contac#ars have ship and have na.emplayees. $..❑Demolition waddng forme in any capacity. employees and have wo&.ers' 9_ ❑Building addition. [No wormers camp.insurance comp- nc'e-# required] 5. ❑ We are a corporation and its 10.❑Electrical repairs or a,&km 3.❑ I am a homeowner doing all work officers have esemised tht& 1 L❑Plumbsag repairs or additions o workers' right of exemption per MGI. €� '�P- 12-❑Roafrepai=s insurance required-]F c.152, §1(4�andwe haven employees_[No wars' 13.❑other camp_insurance required.) #fray wKcmt&at cbedmbos iTl mast also fillautthe sectioabeioa shmaing&ekwalere compeasatiaapeEcg infnundon- I Hamemnerswho submit this affidavit ingn[ating they ate daiz all vat and then hie outsidecoatractorsmnst submit anew affidnit indicating such- IConttactots ffW check tlds box mast attached m addWana2 sheet shming theaame of die sdb-ca=wAo-a sad stda whether or not those eaddeshm employees.Ifthemib-coati ctmhm mWlcyee%Mey=rsrpmvide ffieir worken'comp.policy number I atr�an erreg r heat is pret�zdittg ivarkers'courpertsaticrr�insriranca for m}*enrpf es SeI01v is the paticy aMd jab srte h7fonnatian. Insurance compamyName: Policy-4 cr Self--ins.Lic. F-Viration Date: Job Site Address: CitylState121p: Attach a copy of the workers'coaapensatioapolicy declaration page(showing the policy number and e3Tiration date). Failure to secure coverage as requiredvnder Section 25A of MGL m 157 can lead to the imposition of criminal penalties of a fine up to$1,540:00 an&or one-year imprisonment as well as civil peualties.in the fog of a STOP WORK ORDER and a 1-me of up to$250-00 a day against the-violator. Be ad;dsed that a copy of this statement maybe forwarded to the office of Investigations ofthe DIA.€or insurance coverage verifiCation_ I aFo hereby cgrh jardtsr g panes and i ta�f F&jxiry ThatfPre imfarv�xa#it�rr prat abare is bar$midctrrrect Date: �lJ phone 02kial use only. Do scat write in fiats area,to be minpLTeted by city artown a,f)`icfat City or To*n.: PermitUcense# Issuing Amthor€ty(circle one): 1.Board of Health 2.Building Department 3.CtyFown Clerk 4.Electrical Fuspector S.Plumbing l apeeetor - 6.Other Contact Person Phone#: ' C Information and Instructions 9 M ms;Wl,nce#ts Oeham-g Laws cb.Eq r M req==all employees to provide workers'compensaf1on for t1==empIoyee;.s_ pmsuantto this stat afe,an ernpk5 ee is defined as.';every p=6iL in the service of another under any contract of hire, e-press or implied,oral or wtiftea" An.er"Slvye-r is defined as'an indxvidaa.I,partnmship,association,arrporation or other legal entity,or any two or more of the foregoing engaged in a Joint else,and rnchiding the legal representatives of a deceased employer,or the receiver or trustee of an individual,pa ftu ship,association or other legal entity,employing employees- However the owner of a dwrj ing horse having not more thm tbrw apartments and who resides therein,or the occupant of the - dwelTmg house of anofer who employs persons to do mainirnan ce,caus(rnrnon or repair work on such dwelling house or oa the grounds or building appurte:uant therein shall not bwanse of such employment be deemed to be an employer." MOL chapter 152,§25C(6)also StatPS that'every state or local licensing agency shall withhold ffie issuance or renewal of a Been a or permit to operate a buskess or to contract buRdings in the commonWealth for any applicant who has not prod-acedwith the acceptable evidence of cdmplrance,w the insurance coverage re quiz ed_" Additionally,M(M chapter 152,§25C()states'Neither the corm oawealih nor any of its political subdivisions shall enter into any contract for the pmfomaance ofpublic work-tmtl acceptable evidence of compli4acevAth the mina ce. requn ements of this chapter have Been presented to the contacting auiho&y." Appric Please flI oat the woi3='compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,srpply sub-contractors)na ?e(s), addresses)and Phone Tn— er(s)along with their certtllcai e(s)of ainz ance. Limited Liability Comps i gZC)or Limited Liabdify Partnesshtps(LI.P)withno employees other.thm the members or partners,are not rued to c=y work='compensation inssuzance If an LLC or LLP does have empIoyees,a policy is rMinfil d. Be advised that this affidavit maybe submitted to the Department of Industrial Accidents for confrrmaii.on of insurance coverage. Also be sure to sign and data the affidavit The affidavit should be-retumed to!he city or town that the application for the permit or Iicrose is being ruFnsted,not the Departenf of . Lndns -ja1 Accidents. Should you have any questions regavdmg the law or ifyon are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-rosined companies should enter their self-fiism r,i license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete andprinctedlegibly. The Departmenthas provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigation has to contact You regarding the applicant Please be sure to fill in the pen it cense nnmber which will be used as a reference nnmber. In.addition,an applicant ffiz±must submit multiple pennitlIrcense applications in any given year,need.only submit one affidavit indicating caa-ent policy infbrmati n.Cif necessary)and under"Job Site Address"tie 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 tovrn may be provided to the . applicant as proof that a valid affidavit is on hie for fie pemits or licenses. A new affidavit must be filled olt each year.Where:a home owner or citizen is obtaining a license or pmmitnotrelated to any business or commercial Tmitze (i-e. a dog license or peunit to bimn leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cocperafion anal should you have any questions, please do not hesifate to give us a call. 'The Department's address,tElephone and fax. T=ber. Tha ammmWeE M of ch�tts IIega�ime�cif Izidr�ial Ac�Kl�nts . ��asbin�Qn Sty Bosom IA Q111 Tc,-L 4 617 727-4 c-xt 4€6 Qr -M-MASSAM Fax 9 617 727 7749 lZevised 4-24-D7 �� �e Town of Barnstable Bud>fng }�egartment:_ hues. 'Bnan`Ftorence;CBU; •_ , . c; ct►. Bntlding Coimntssioner" 00°Main-Street;Hyannis,MA;°0201. ,*0 W,fown.barustable ma,usr Office: 50$-862-403$ Fax.:548=790-6230 Property , r Must ': Complete arid•Sig� Ths Section: " . ;- . If Using A $under(JA `. I � ,.as:C?wnes:of the sub ect ro hereb. authorize - p (7 to act o m7 behaif,,. in all Matteis relative to work authbiulid l y thus"huilding permit application far: `> 1111 :: - (Addsess of j b - Pcol fences.and'alarms-are the responsibility of the applicant.Pools. - are not to be filled or utilized before fence,is.installed grid all final in ns are fosmed and accepted. Signature:'o Applicant { P=tNatne Print Name 1 D to 0 Q:FORMS:t)WNW.bOvi Sj&pwLs Rev:10/1.7 . f (921e cCarnrrean�aealC�a�C�J/laa�cac�uae Office of Consumer Affairs&Business Regulation Registration valid for individual use only HOME IMPROVEMENT CONTRACTOR 9 TYPE:Individual before the expiration date. If found return to: Rea{stratwn Expiration Office of Consumer Affairs and Business Regulation 179053 # 08/13/2020 1000 Washington Street-Suite 710 z Boston,MA 02118 CHARLES PISACANO 4;` A, x d CHARLES PISACANO 73 HARBOR BLUFFS V Not valid without signature HYANNIS,MA 02601 Undersecretary 3 i i Commonwealth of Massachusetts Division of Professional LjC d standards wilding Regulations and Board of B %t 'A SS�rvisor Const�' ion ,-E�P 19 ices 07129120 CS-086733 } Al. i Tr Ji rf CHARLES PISACANO, 64T 5 PO BOX 126 HYANNIS PORT-f�AA Commissioner R - TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel TOW Or- ARNSTABLE Application # Health Division ?!�1 ..j€"b.. 2 '' ���j Date Issued /2-n Conservation Division Application Fee Planning Dept. �,Tr Permit Fee 5 J. Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address 3 t C'n� Q As, H!n As N Mr 6 Z 6 a 1 Village Owner \�)L n vl r 6L,A Address 3 A = M f Telephone rid k Z L — �1 '� o - Permit Request t/ Q r Sr%P< ��2 " { �(� — Z Z Ce_ U 00re-0 a [ 40, h1�f ( ?d o I It l3 + �—► ec J uare feet: 1 st floor: existing proposed 2nd floor: existin4 proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 13 Construction Type Lot Size / Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family d' Two Family ❑ Multi-Family(# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft)- Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing —new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: i❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review # Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name DIV, l Telephone Number 6t>I-) �l 5 (,Lf YG Address p 6 Q2a�r aS� License # � '7 ? I �c�Z'L c7N� 6d�? I Home Improvement Contractor# 1 a 7 1 Email be, Mktk �J 9 '1 G An Worker's Compensation # a I ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TOG PAxr-1 SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED z MAP/PARCEL NO. ADDRESS VILLAGE i" OWNER Ia DATE OF INSPECTION: I' FOUNDATION FRAME INSULATION r FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL I� FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. r Town of Barnstable 0 Regulatory Se ces KAM $; `- Ricbarit'V.ScaIi,Direc ar sbJ9A 10 ,. Building Division Tum.PemvY Builiiing.:Comri'►moluer ' 200 Main st�et>11)wd;si ii,MA o?6ni r ' i��wv�.ta4vn,bal�nstahl�:ma,us , Of lcc: 5.08-9624019 Tar'. 50&790.6230 ropl3 rt OWD'e'r mw.t Coinplete and Sign.rh s Sector a( I, as-C)NmIer of nc�.subject ro eii:: . dIr �. I P � Y hcrcbyaudhorizeQ l'L � , C to act on my behalf; in,Z mamzs mlauvc to work authorized.by this v Qding pemvt appEc Ltion for: {A:ddress of f oU pool fcpn;cs =d, are the responsIIt=of t p Izcaz,t:P.t�0Is ire not ro be,filed or utilized before,fence 5 installed and aU final. spe arc armed and accented_ Sigaa r Signature of.AppUc=t Lx Punt game Pii� .Narm Q;Fo�nls;�w�,' F�trtiss�oz��v�:s \ The Commonwealth of Massachusetts Department of IndustrialAccidents I Congress Street, Suite 100 Boston, MA 02114-2017 ]V V www mass.govli is NVorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le ibl Name (Business/Organization/Individual): eJ p Address: n (lcx 10 City/State/Zip: 0311( Phone#: ��eJ�Lf r /0 J� Are you an employer?Check the appropriate box: Type of project(required): l.@'/Jam a employer with_____/,(Lemployees(full and/or part-time).* 7. ❑New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in $. Remodeling any capacity.[No workers'comp.insurance required.] 3.[D I am a homeowner doing all work myself.[No workers'comp.insurance required.]; 9. ❑Demolition 4.O I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.Q Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.[:]Roof repairs �. These sub-contractors have employees and have workers'comp.msurance.t tD 6.�We are a corporation and its officers have exercised their right of exemption per MGL c. 14.®Other tAh,,-9&'1 2 c,TJrI'1 152,§1(4),and we have no employees.[No workers'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. lContractors 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. 1 am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: S �^�, �.,• S (20• �y r Policy#or Self-ins. Lic.#: . �— d 6�{J�C�O I 00 Expiration Date: b 0 ' h7 Job Site Address: �, /4/O rN '�-r City/State/Zip: � ,iy/V►S /�44 Attach a copy of the workers' compensation policy d claration page(showing the policy number and expirati6n date). 6 Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerhify under the pains andpenalties ofperjury that the information provided above is true and correct Si ature: Date: 7 .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#: Client#: 317787 RETROFITINI ACORD,. CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDNYYY) 810 512 01 5 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be 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 sucr,endorsement(s). PRODUCER - ONTACT NAME: HUB International New England PHONE 978 657-5100 FAIL A/C No Ezt: q/C,No): 978-988-0038 222 Milliken Blvd E-MAIL Fall River, MA 02722 ADDRESS: 508 235-2200 INSURER(S)AFFORDING COVERAGE NAIC p INSURER A:Star Insurance Company 18023 INSURED RetroFit Insulation, Inc. INSURER B PO BOX 105 INSURER C: Seekonk, MA 02771 INSURER D: INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ADDLTR TYPE OF INSURANCE NSRL WVD POLICY NUMBER UBR MAOAlDDY EFF MM DID/YYYYPY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMIAGE TO RENTED PREMISES Ea occurrence $ CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident S AUTOS AUTOS � ( ) NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION AND EMPLOYERS'LIABILITY Y/N WC084520100 8/02/2015 08/02/201 X WC STATU- OTH- ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1 OOO OOO OFFICERIMEMBER EXCLUDED? � N/A (Mandatory in NH) If yes,describe under E.L.DISEASE-EA EMPLOYEE $1 OOO,OOO DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. p ACORD 25(2010/05) 1 Of 1 The ACORD name and logo are registered marks of ACORD #S1432002IM1432001 RB004 i Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston,Massach- setts 02116 Home improvement Registration tY>.�.. .,5. Registration: 160461 Type: Private commton Explrgtion: 71 MO1S Tr# 2MI84 RETROFIT INSULATION INC. JOSEPH REILLY P.O. BOX 105 SEEKONK, MA 02771 Update Address aid relu rn card.Mirk reason four chugs. [] Address Renewal Impiopment Lost Card SCA 1 w 2UM-OW11 �omm"earuc+ dc o�Caobac/aaceelld Offiae dConsumer Affairs&Bu iwa Regulation License a r�,GtiOn d valid for wd retur use only HOME IMPR CONTRACTOR before the eaPiratiolt datie. Xf fomd return to: Offm of Couanmer Affairs and Business Regulation rstradan,..16a461 Type' 10 Park Plana:-$v to 51.70 EXr -' 8 p, Private cmarsoen Xwhng MA 02116 J+ RETROFIT INSIII MAi,`aN `'-, JOSEPH REILLY FALLRIYER.MA 02721 undersecretary Not valid without signature MasaaeAusatta.Department of Public Sabty j BOOM of Building Requlalions and Standards r6n,tructinn Supen'im-?-S cci�ettF Lkenae:CSSL-10,�771 N, JOSBPM J R]9=4. 'y PO BM 105 Seeroak IYiA Q1!771 r s• �a r� Comrnis�oner '�je Expiration i OBNXM17 { 1 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map- Application# 11V�W� Health Division Conservation Division Permit# Tax Collector Date Issued A 310 7 Treasurer Application Fee Planning Dept. Permit Fee �- Date Definitive Plan Approved by Planning Board P— Historic-OKH Preservation/Hyannis Project Street Address A idem i Village f./ N tj k.N i Owner f',K .Soli( Address ���IU• ��f �{�iisr`��!! �ec�e�l� r� �� Telephone 316 - -' 4q24 R0)fl Permit Request �� fo �6:9 t" Vl Square feet: 1st floor:existing proposed 2nd floor:existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure �M Historic House: ❑Yes U4 On Old King's Highway: ❑Yes & No Basement Type: Ur ull UrCrawl ❑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 I new Total Room Count(not including baths):existing new First Floor Room Count Heat Type and Fuel: &has ❑Oil ❑ Electric ❑Other Central Air: ❑Yes Li o Fireplaces: Existing I New Existing wood/coal stove: ❑Yes U o Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: t , -71 Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ `- �. two Commercial ❑Yes V/No If yes..site plan review# Irk Current Use S✓tea L� Proposed Use „Lb BUILDER INFORMATION Name Pr c95 cx & Oey Telephone Number ��- ��-cl d�l Address tkiff License# ��?; &4 P y Ott k kA Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO L,t+. ,_ SIGNATURE DATE �% t FOR OFFICIAL USE ONLY - e PERMIT NO. DATE ISSUED i MAP/PARCEL NO. ADDRESS VILLAGE OWNER = DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ti I 5 ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL f FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. s Table JS=b(continued) Prescriptive Packages for One and Two-Family Residential Butidings Heated w'itb"Fostii Fuels MAXfMUM MINIMUM Glaring Glazing Ceiling Wall F3oar I Basement Slab 'Ht8dng/Cooling Arm' U-value= R-valutr R-value' R-value° Wall Paimeler Equipment Etlicicney' Pie R-value' R-valuer 5701 to 6500 Heating Degree Days' 12% 0.40 38 13 19 1 10 6 Normal R 124/a 0.52 30 19 19 10 6 Normal S 12% 0.50 38 13.. 19 10 6 15 AFUE T 15% 036 38 13 25 N/A N/A Nonni U 13% 0.46 38 19 19 10 6 Normal V 15% 0.44 38 13 25 NIA N/A 85 AFUE W 15% 0.52 30 19 19 10 6 85 AFUE X 1 18% 032 38 F 13 23 N/A N/A Normal Y 18% 0.42 38 19 25 NIA NIA Nonnal Z 18% 0.42 38 13 19 16 6 90 AFUE AA 18% 0.50 30 19 19 1 10 6 90 AFUE • r 1. ADDRESS OF PROPERTY: 2. SQUARE FOOTAGE OF ALL EXTERIOR WALLS: 3. SQUARE FOOTAGE OF ALL GLAZING: 4. %GLAZING AREA(#3 DIVIDED BY#2): 5. SELECT PACKAGE(Q—AA-see chart above): NOTE: OTHER MORE INVOLVED METHODS OF DETERMINING ENERGY REQUIREMENTS ARE AVAILABLE. ASK US FOR THIS INFORMATION. BUILDING INSPECTOR APPROVAL: YES: NO: q-forms-580303 a °-'THE r° Town of Barnstable Regulatory Services BARNST"$LE, ' Thomas F.Geiler,Director y nsnss. 16.19. n i� 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 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: bitplAA1 . ee. - Estimated Costo Address of Work: (Q Owner's Name: Date of Application: U`' I hereby certify that: Registration is not required for the,following reason(s): OWork excluded by law ❑Job Under$1,000 OBuilding 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 PERJURY I hereby apply for a permit as the agent ot the owner: Date Contractor Signature Registration No. OR Date Owner's Signature Q:wpfiles.forms:homeaffi d av Rev: 060606 f 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/In(lividual): l' (.� cas C', Address: City/State/Zip: Phone#: Are yo n employer?Check t e appropriate box: Type of project(required): 1.EYam a employer with ' 4. ❑ I am a general contractor and I 6. ❑Nex 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. t 7 emodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]t 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 their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: ° V �1 l �L"l 6rat* Policy#or Self-ins.Lic.#: �� . `L f�" Expiration Date: - (0 Job Site Address: 3 J 12 n 0 Q R V1 cS City/State/Zip:`_,M__,� U/7L • Attach a copy of the workers'compensation policy JeclaraihIon 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 certi der the pains and penalties of perjury that the information provided above is true and correct Si ature: Date: Phone#: 9T-4�.A6T_ ,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#: I r y 0oard ofhBudding Regulations and Standards j t sC011StGUCtiOn S:upervi'sor License 1 { s License CS 43-56 ' B ithdate=121 ' '[—2 : i 3 E.pir5tiont 1 1K3/2•©08` "T l festrlct00 t?l jl ^p SCOTT E CROSBY�� F. i OSTERUILLE MA_02655. Commissioner J I . Board�B�Id nglRe`niaat ons'ana a d g g 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' J51882 One Ashburton Place Rm 1301. ExpiraUq,n 7/13/2008 Boston,Ma.02108 Type Pn a.Ee Corporation SCOTT E CROSBY BUILDER INC'f SCOTT CROSBY 1112 MAIN ST UNIT#�7 ;� j -- withou signatur OSTERVILLE, MA 02655 ::} Deputy Administrator Not valid t t 111/�/1oo6/200//6�� 14:59 FAX 5084283068 GERMANI INSURANCE �001 l ATE MMIDD/W/ ,. . °ii'p14e19NIYIh1nm111Y64 blc,l+.:»nna' ., Idl:-.,: 1 ��;I�r_.ril�«Iu .1, nI1.11.._N ,r 11./16/2005. A.PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE GERMANI-INSURANCE AGENCY ;.. HOLDER.. THIS CERMF=TE-.DOES- NOT AMENn,.EXTEND-OR-:... 908 MAIN STREET ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. OSTERVILLE,MA 026S5 _ COMPANIES AFFORDING_COVERAGE- COMP - AANY ESSEX INSURANCE COMPANY - ........._..._._.. . .. ...._.. ._... .. _- . ..._._. -------------- _. ... INSUREtY COMPANY SCOTT E.CROSBY,BUILDER, INC. g AIG AMERICAN INTERNATIONAL GROUP 62 CROSBY-CIRCLE.. .. _._.... ....... ..........._._ —. --.._ OSTERVILLE,MA 02655 COMPANY C . ..COMPANY D I,.. •fP'�Si? 1 44 } :1}i dt. ..}{ i•(.I'9!i n:l;l,;,�.r,iI..:.A•- 1 it'P,? .�qy: P I •.R a r•r 9t '!':;,9? ::c,:v-.?�� -:�r:n;rv'.cv�'::.r,i�ni�,,I„II�31II-�I ,S� ",I,,f,l III , i,. Gi r,l,, ,'+,i �tlrl1�'}I t I ,. �U ,•,�,,(ly,l {.(i�. r.P!t,; - •,Q`,d.•.,. .1ri:. .....a 1�.1, ,a, t I-,V, 5d'�•,lt.;i"t•,ta•,��t.n,i,r.•�i,'�a}Ilhtl%a.i•a,�i'Vlb�•'.ra Y6; ,l i' !-r r ": �a ,Y„,`i'4r•, ., � ... :, 1 ,uln ,INthI„�nfl"u t�lux a, , a ..,•..,I.(hL II_L.t.:;t..t......rl�.�.._I ..�,:.!fti.m li!Illu,l„I,i,mu::,a.m,,,_,_r,-.:dr.'i.l.:e..l..,.'u,.._L__.a,....liri._..a....•„i.:..t!.^.1.._ . THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING.ANY REGUIREMENT,TERM OR CONDITION OFANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERI II-1 tTE MAY BE-ISSUED OR MAY PERTAIN,THE INSURANCEAFFMWED BY THE POLICIES DESCR16E0 HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ----------------- LTR I TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS DATE(MMIDDIYY) DATE(MMIDW") - GENERAL LIABILITY GiENFRALAGGiiGGATIi... 1.-.. QOO 004--_ A 3CU9430 )( COMMERCIAL GENERAL LIABILITY OT�06/Q6. OT�OJ�OT -•'_.._.._._____ - PRODUCTS-COMPIOP AGO.-S - - - CLAIMS MADE OCCUR . '. - .PER8ONALSADYllV1LIRY�:, I .. OWNER'S-d CONTRACTOR'S PROT- EACH OCCURRENCE .-1 . 110001000 - -FIREOAMAGE lAny one tire). ;.. MED EXP(Any one person) 3 AUTOMOBILE-LIABILITY ANYAUTO COMBINEDSINGCEUMIT •8- -ALL_OWNED AUTOS-- -. BODItY n'rwR'r. 1, SCHEDULED AUTOS (Per pardon) HIRED AUTOS _ 00"Y IPFJURY. .... NON•OWNED AUTOS (Per eccwenq .... .... .....--'---..._.. .. - PROPERTY DAMAGE, GARAGE LIABILITY AUTO ONLY-CA ACCIDENT S ....................�_ANY AUTO OTHER THAN AUTO ONLY: EACHACCIDENT S AGGREGATE_ 8 EXCESS LIABILITY EACH OCCURRENCE S UMBRELLA FORM - - . AGGREGATE .$.... . OTHER THAN UMBRELLA FORM 1 8 WORKER'S COMPENSATION AND WC 896-31-13 06/22/06 06/22/07 WIC OTATIF _,0" raRVUMtTe ER. _.._. EMPLOYERS'LIABILITY EL EACH ACCIDENT :i — - $- OO OOO — .. __• THE PROMETOR/ INCL. .. . . '... ...-.. EL OISEASE-POUCYLIMIT t- SQQ�QQQ" OFFICERS AAE: HEXCL EL DISEASE-EA EMPLOYEE S 100,000 OTHER DESCRIPTION-OF OPERATIONSILOCATIONSIVEHLCLESISPECIACJTENSS-:._.,. . .. I` r•!;, ... ,... '��1�............. I } t��h,n&d. t„ 1L..� 11dla,d�lltd:•.h:'•t,l,,,,,,laic , ,. !,:•.: „I!(, I',! i::;; SHOULD ANYOF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE iXDWATION-Wl'CB-TNGRi -THE-L4i Polo rCOMPAM*-WNL•FNDFAVON-TO•-MML 110 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, _. BUr:FAUXREIT MR rlCK NCTMESHALLUAIPUBE_D{OOQLIGATIOH-.OR.11A8AI LU--.....,, Of ANY KIND UPON THE COMPANY ITS .AGENTS OR REPRESENTATIVES. AUTHOr REPRESENTATIVE r�i rl;,,,,,.,.,1;`r s � •,rt(l{i(ql i I� r N rl.,�'�i 1 i i.na �i,u;,la`I,,IIII,}�,mlllrrqn I gills (I . • „r,.,."•.,:...,.,. ,r r u I�,(:;r; .!:!;;�,hmF:;.r:.,:c•12,.v I�d:•,, .. e: 2007-Jan-19 01 :08 PM E! Networks 3239542660 2/2 Jars 19- 07 03: 41p [508] 428-3005 P. 1 s Town of Mirnstable Regulatory Services Thomas t�Miler,�reeto� _ . . Building Division [building Commssmoner �df1 '�erL"CR;-�yt4TII119;��' vnv�,tuvs'a:bnrnsknbl�enu.aM Office: 509=867-4038 l+=. 509-790--6 ' 130 W®peft~... ..,. If Using A Builder hereby au>lio�tze° r..`. f's ' '�E E:..r�. has ►tay.Fie in;ill rn W<-j*-guth�tr $ytfixs :perratata�p�ecatio oc: (Address of Job) U0. ;signature k&ner Due pdill 2alle � Q:Fvrm3:expmtrb Repheeq 005.