Loading...
HomeMy WebLinkAbout0094 BAXTER ROAD`- III !I h S t Town of Barnstable Final Inspection Affidavit f Date:s_1�� Building Division 200 Mair-Street Hyannis, MA 02601 RE: Insulation Permits Dear. This affidavit is to,c rtif thatI,work completed at: Street: ' �(•�-� Village: has been i s cted by a certified Building Performance Institute (BPI) Inspector. All work performed meets or exceeds federal and state requirements. Permit.applicati ;(��-umber /' 330 Issue date: Sincerely, a Francis Sheehan President Frontier Energy Solutions, Inc. 502 Harwich Road i Brewster, MA 02631 Office: 774-237-0410 1 Email: fssfrontierenergy@gmail.com w � J. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map C Parcel Application # Health Division Date Issued Conservation Division Application Fee Planning Dept. Permit Fee _ Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis EM!ESL S �1 Project Street Address T4 bnxtm Villageoa5 MA 046o' Owner 'L Address 9�/</�,�}OD Telephone �—i — �I Permit Request (,V 3)SO-k 1 e-A (:a;, O,q-fL J`�' 00 S g�l L J?J,U,-0--,�a - �-Q- , :31-�n suil- ti Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 000 Construction Type hjf' Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family 1�-"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 (fj��� Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/ al stove: 42i� ❑ No Detached garage: ❑existing ❑ new size—Pool: ❑ existing ❑ new size _ Bft, exis i46 W size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other —& Tqe�� Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial p Yes � If yes, site plan review# Current Use Proposed Use � ` .�2. APPLICANT INFORMATION (BUILDER OR HOMEOWNER) _ Name-�'b'� ,�F �� `� Telephone Numberr714 0 Address ° ���% ram' License # 1 Home Improvement Contractor# c� s `1 EmailM L))We7_':Q;a2GC�i p &r rk 's Compensation Wt l 00601 l a 0! b 0 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PRO ECT WILL BE TAKEN T i�- SIGNATURE DATE R FOR OFFICIAL USE ONLY r APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION a I' a FRAME , INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. ' 1 Jan 20 '200 9: 51AM ' HP LASERJET FAX p. 3 o . blip. -Rog"s s ..sler,v. r. , ��� �..per. ;r7 }71i'YiWvM •' dim ol• �,: F Q rrJEQ Y 7t3.g�]�,t gig:[L°�p S Co'pR�D l 1. 1�I5 ation for. L _.... . i • c; r l License. registration valid for individual use only pt7ice.of Consumer lffairs Business Reulation beforeahe expiihon date "If tound"return"to: ! "= HOME IMPROVEMENT CONTRACTOR flffice.'of Consumer rlffaics arid;Business Regulation ` t Registration 1,6085:4TYPe' 10 Parlc'PlazaSmte 5:1-70 .Expiration 91812018. LLC Bostan;,NX14 02a:16. { FRONTIER ENERGY SOLUTIONS" i FRANCIS SHEEHAN x 1 502 HARINICH RQ f} s — . ;._. �. _... I. $REWSTER,MA02631 '' Lrdersecretaij N t val' ithou �igpatii"re Construction Supervisor Specialty r' Restricted to: � assaci use##s bepartf lent oP I�u,biac Safety 1- CSSL-IC- Insulation ContractorB©adsfus[c3in� l2ezulat;aris,anci Siantlards License CSSL 105941po Ce�r�s rei Suerusc rpec i#y g FRANCIS S SHEEHAN`. r 562 HARWICH RD BRE"ER A4 0263F1R Failure to Possess a current edition of the Massact%usetts State Building Code is cause for revocation of this license. DPS Licensing information visit:`WWYV.MASS.GOVIDPS F" vrr; siCr?e r ;02/17/2018 1 , i J � . The Commonwealth of M'asserchcasetts De artment of Indtcstrirtl Aceidents "1 .1 Congress Street,suite IOl1 Boston, MA 02114-20.17 ►tnvw mass govIdia NN'urkers' C:ompensa'aion Insurance Mridavit.Builders/Contractors/Electricians[Pitttiibe-rs. '1'0 BE FILE 3 WITH THE PER�[I'i i'iNC. lI CHOIZI7'Y. Applicant Information - Please Print Le ibly Name(Business/Organi2ationl['ndividual:j: IZ( Address: Ci /State/.Zi : r 2 S+Q-r, ar 9 . l Pliorie# Ace-you an employer:"Check the,appriip.riate box: Type Of project:(required): l,�am a�cmployer with 1 � cmpioyees(full andlor part-time).* 7. ❑New construction 2f�1 Am.a sote proprietoror partnership and have no employees working forme in 8. ❑ Remodeling any capacity.[No workers comp.insurance required-] 9. []Demolition 1CD l am a homeowner doing all work myself.[No workers'comp,insurance required.] 10 C] Building addition 4,❑j am a homeowner and will be hiring contractors to conduct all work on my property. 1 will ensure that all contractors either have workers'compensation insurance or arc sole 11,E]Electrical repairs or additions proprietors wiih nn employees. 12. Plumbing repairs or additions �. . I atn-a.general contractor and t have hired the sub-contractors listed on the attached sheet: tt i ❑ 13. Roof repairs t ! 'These sub-contractors have employes and have-workers'comp insurance.. ++ L 6. We area corporation and.its officers have"exercised their rigl t.ot exethption:per.Mi GL c. 1.4,�ther i 152,§1(4:):"and we}rave nti t tnpoyees,liVo worker's'comp.insurance required,] "Any oticantathat checks box 91 muist also tdiout the section beldw showing their Workers'compensation policy information. t Homeowners Who submit this afdavit tndteating.they are doing ail work and then"hire outside contractors must submit a new affidavit indicating such. tContraLlors fllett check Oils box must attached an additional sheet showing the name of the sui-contractors mid 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 pro vidina workers compensation invarance for may employees. Below is the policy and Job site information. t - Insurance Company Name: All ` K C .\ i�. '�s �uyrC.SL: Q !v:,. 't Policy#or Self.-ina:Lic.#:U°�Ui'>-(�i(J } `' '�� s Expiration hate: ;/(y{ 7 t? 7 Job Site Address: City../State/Zip:P Attach a copy of the wor e:rs'compensation polity,declaration pa„e(showing the polity nun er and exp 10 i Failure to secure coverage as required under MGL.c: 152,§25A is a criminal violation punishable by a fine.up to$l 500.:00 t and/or one-year impinsonment;'as well as civil.penalties in the form of a STOP WORKORDER and a.fine of up to$250.00 a. ` day against the violator. A copy ofthis- statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 l do-herebycent under the ains a 'ties a er'u. that the in orntation provided above is true and correct fY p IP t ry f P i signature. bate: Phone 4: -7l-{.- Dfjicial use only. .Do not write in this.area, to he canwpleted by city or town off ciai t • City or Town: Permit(License 4 I Issatng:Authority(circle one): L.Boardjof Health 1.Building Department 3.C tyg6*n Clerk 4. )electrical Inspector 5. Plumbing inspector 6.Other ' . Contact Person: Phone#r � �' t / ® .,�• DATE(MMIDD/YYYY). A CERTIFICATE OF LIABILITY INSURANCE ; . 04/05/2016 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,pertain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). / PRODUCER NAME:CONTACT Krystal Doyle ' ROGERS &GRAY INSURANCE AGENCY, INC. P"�N E:t: (508)398-7980 AIC No: E-MAIL - ADDREss: kdoyle@rogersgray.com 434 RT. 134. INSURERS AFFORDING COVERAGE NAIC# SOUTH DENNIS MA 02660 INSURER A: AIM MUTUAL INS CO 33758 INSURED INSURER B: FRONTIER ENERGY SOLUTIONS INC INSURERC: INSURER D: 502 HARWICH ROAD INSURERE: BREWSTER _ MA 02631 INSURER F COVERAGES CERTIFICATE NUMBER: .42389 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. INSR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER MM POLICYEXP DD/YPOLICYEYYY MM DD/VYYY LIMITS LTR COMMERCIAL GENERAL LIABILITY - EACH OCCURRENCE $ DAMAGE TO RENTED CLAIMS-MADE OCCUR PREMISES Ea occurrence) ccurrence $ MED EXP(Any one person) $ N/A PERSONAL BAOVINJURY $ GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑PRO- LOC PRODUCTS-COMP/OP AGG $ JECT OTHER: - $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident _ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS. AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE N/A - AGGREGATE $ DED - RETENTION$ $ WORKERS COMPENSATION /� STATUTE EERH' AND EMPLOYERS'LIABILITY ANYPROPRIETOR/PARTNERIEXECUTIVE YIN E.L.EACH ACCIDENT $ 1,000.000 A OFFICER/MEMBER EXCLUDED? N/A N/A, N/A VWC10060153152016A 03/14/2016 03/14/2017 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ '1,000,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees'outside of Massachusetts. This certificate of insurance shows the policy in force on the date.that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at Www.mass.gov/lwd/workers-compensation/investigations/. 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. Frontier Energy Solutions Inc ` 502 Harwich Rd IAUTHORIZED REPRESENTATIVE Brewster MA 02631 Daniel M.Crowey,CPCU,Vice President—Residual Market.—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and,logo are registered marks of ACORD i 'TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map J/0 Parcel Application# Health Division, a�� D 'j�, �✓,,, ,u ,r Conservation Division Permit# 2-z Tax Collector Date Issued t Treasurer D� Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board CONNECTED SEWER ACCOUNT Historic-OKH Preseration/Hyannis Project Street Address 04XAzf Village .; . . :� Owner C�.���Y����', lM 1��� � Address ,^ us Telephone �SC, qA0 31 ft 90 ` Permit Request r ° :> S - �C e k - 4 � :rlLrn All �.►r /UJ .ec c - .� cam✓,4� ''Ji:+6 In � S�}�r1L uare feet: 1stfloor:existing proposed 2nd floor:existing Atp proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation ,tZ70 Construction Type Lot Size_ � Grandfathered: ❑Yes 6Ao. If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) -- Age of Existing Structure m ` S9 Historic House: ❑Yes C<o On Old King's Highway: ❑Yes 4Tlo Basement Type: ❑Full ' yp ravel �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 Cou t Heat Type and Fuel: U'Gas ❑Oil ❑ Electric ❑Other Central Air: ❑Yes O' ll�o Fireplaces: Existing . New Existing wood/coal stove: ❑Yes W Detached garage:❑existing ❑new sized Pool:❑existing ❑new, size Barn:❑existing .❑new size Attached garage:❑existing ❑new size ti✓ ) Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial O Yes Wello If yes,site plan review# 0 Current Use Proposed Use ' BUILDER INFORMATION Name Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# ALL/CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO x. L —-SIGNATURE DATE � TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application# Health Division 40k Conservation Division Permit# 2Z Tax Collector - Date Issued l ko Treasurer o Application Fee D� Planning Dept. Permit Fee 5-® Date Definitive Plan Approved by Planning Board CONNECTED SEWER ACCOUNT � �7Y Historic-OKH Preservation/Hyannis Project Street Address Village7 �+ +3 Owner r-4ry1)e_ 0:11414T Address ell /ev S Lr} � m� A TeIeph0n 09 q;LQ-SY cam!( SDI,28y- �?Y ED Permit Request ,�� Al— Re c� C',� sal •uf qua re feet: 1 st floor:exis ing_Y� proposed S4Me— 2nd floor:existing A 0 proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 17Z7O Construction Type Lot'Size Grandfathered: ❑Yes W(No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure 7v,1Ary Historic House: ❑Yes LiP<o On Old King's Highway: ❑Yes' O'No M r4. Basement Type: ❑ Full rawl ❑Walkout ❑Other ' aN _ .. 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 Cou t Heat Type and Fuel: ®'Gas ❑Oil ❑Electric ❑Other Central Air: ❑Yes O'I o- Fireplaces: Existing New Existing wood/coal stove: ❑Yes [moo Detached garage:❑existing ❑new sized Pool:❑existing ❑new size Barn:O existing ❑new- size Attached garage:❑existing ❑new size &0 Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization O Appeal# Recorded❑ Commercial ❑Yes La-< If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION p Teleme Na hone Number I Address License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO Alf —SIGNATURE DATE s FOR OFFICIAL USE ONLY 'f PERMIT NO. ? y n DATE ISSUED z MAP/PARCEL NO. ADDRESS 1 VILLAGE OWNER " r' DATE OF INSPECTION: FOUNDATION FRAME INSULATION 0IL FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH ® ' FINAL GAS: ROUGH 3 FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. 1 r I� I `pFSMETp�� The Town of -Barnstable - WP O� N BARNSTABLE. • Department of Health Safety and Environmental Services: MA55. 0a 039. �0 OM°y° Building Division 367 Main Street,Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 = PLAN REVIEW - Owner: Map/Parcel: Project Address: 7`'i c - ��� Builder: The following items were noted on reviewing: _ C C4.7QC9 U0 CIAD c �, r cc) �- ep Reviewed by: Date: Department of Industrial Accidents Office.of Investigations 600 Washington Street Boston,MA 02111' ' ••'-' www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plunabers AlDplicant information Please Print LeEffily Name (Business/organization/lu&vidual): Address: ' City/State/Zip: JYLS '�( Phone#: 1� 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 # ?• [Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition- ''working for me in any'capacity. workers' comp.insurance. g• ❑ Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or.additions ,�equaed.] officers have exercised their 3.( I am a homeowner doi#ig 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.❑ Other comp.insurance re------------ ired] ¢Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information: � t Homeowners wbo 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 most 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: Policy#or Self-ins.Lie.#: 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 STOYWORK ORDER and a.fine of up to$250.00 a day against the violator. 13e advised that a copy of this statement may fie forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi nder e p ' and a 'es of perj the information provided above is true and correct. Sr ature: Dater w /0(1 6 Phone#: Official use only. Do not write in this area,to be completed by city.or town official City or Town: PermitUcense# Issuing Authority(circle,one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 fequires 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 defrried agA.'=indiviSit .:P erghrp association,Farporation or other legal entity,or any two or more of the foregoing•engagedin a joint enterprise,and including the legal representatives of a deceased employer,or the trustee of an individual,p artnership,association or other legal entity,employing employees. receiver or Hov�!ever;tie owner dwelling hous a 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 woikvn 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 produced acceptable evidence-of compliance with the insurance coverage required." applicant who has not ter 152, 25C 7 states"Neither the commonwealth not any of its-political subdivisions shall Additionally,MGL chap § ( ) enter into any contract for the perfo lance of public work until acceptable••evidence of compliance with the insurance Iequirements ofthis 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 numbers)along with their certifieate(s)of insurance. Limited Liability Comeanies(I,LC or Limited Liability Partnerships(L•LP)with no employees other than the • ) members orpartnem; are not required to carry workers' compensation insurance. If an LLC or LLP does have eniployees, apolicy is required. Be advised that this affidavit maybe submitted to the Department oflndustrial 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 Deparfnaent of Industrial Accidents. Shouid you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at u the number listed below, Self-insured companies sho Id enter their self-insurance license number on the appropriate line. City or Town Officials . Please be sure that the affidavit's complete and printed legibly. The Department has provided space at the blot�m of the affidavit for you to fill out in the event the Office of Investigations has to contact you re aiding the app ense number which will be used as a reference number. In addition, an applicant Please be sure to fill in the permit/hc 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 A copy o€the•.a8idavit 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-en file for.future Permits-orlioenses.,Anew affidavit.must be filled out-each or citizen is obtainin a license or permit not related to any business or commercial venture year.Where a home owner g (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.like to thank you in advance for your cogperation and should you have any questions, The Office of Investigations would please do not hesitate to give us a call. The Department's address,telephone and.hx number: The Commonwealth of Massachusetts . Iepartment of Industrial Accidents ..Office of Itavestigations . a f. .600 Washington•Street- . Boston,MA 02111.' " `Tel.#617-727-4900 ext 406 or•1-877-MASSAFE Fax#617-727-7749 Revised 5-26-05 www�ass.govldia Town of Barnstable Regulatory Services 3 Thomas F.Geiler,Director *61 Army . Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www,town.b arnstable.ma,us ffice: 508-862-4038 Fax: 508-790-6230 P ermit 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 constructipn 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 adj acent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. I Ty.pe.ofWork:�p�ny� tlyl Estimated Cost���� Address of W&la 1�J Owner's Name �/, Date of Application: 't I hereby certify that: Registration is not required for the following reason(s): C]Work excluded by law ❑Job Under$1,000 []Building not owner-occupied [jj0wner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITHUNREGISTERED CONTRACTORS FOR APPLICABLE HOME EYIPROVEMENT 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 of the owner: Date Contractor Name Registration No. Owne 's Name Q:forms:homeaffidav RESIDENTIAL BUMDING PERMIT FEES APPLICATION FEE - New Buildings $100.0.0 Residential Addition $50.00 Alterations/Renovations 50.00 _SD Change of Contractor/Builder $25.G0 FEE VALUE WORKSB EET .NEW LIVING SPACE square feet x$96/sq.foot= : x.0041- plus from below(if applicable) ALTERATIONS/RENOVATIONS OF EXISTING SPACE square feet x$641sq.foot= Z x.0041- plus from Blow(if applicable). 7 Y y QARAGES'(attached&detached) square feet%$32/sq,ft.= x.0041= ACCESSORY STRUCTURE>120 sq.ft.. >120 sf-500 sf $35.00 >500 sf-750 sf 50.00 . >750 sf-1000 sf 75,00 >1000 sf=15.00 sf 100.00 >1500 sf-Same as new building permit: square feet $96/sq,foot= x.0041- STAND ALONE PERMITS Open Pqreh x$30.00= (number) Deck x$30.00- (number) Fireplade/Chimney x$25.00= (number) Inground Swimming Pool $66.00 Above Ground Swimming Pool $25.00 Relocationlmoving $150.00 (plus above if applicable) Permit Fee Town of Barnstable Regulatory Services BARNSTABLE, : Thomas F.Geiler,Director 9 MASS. 1639• .0 Building Division �plFD MA'1 s 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: JOB LOCATION: vL/� number street village "HOMEOWNER":�� �/y�/[�- CJ�d,1,1 C(1 name nn 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-pemiit. (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 Homeown 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:forms:homeexempt �v �o I 1 l ( M c I _ r�-_. �` I I O 11 f I ► 1 ' � Q V 3 M --+ a - --- - 4-H TS l� I I I $ I _ I A - J I` t 3..e►._c� _�ra�. x. ___-__ -,.9►_. I 4 i i i i T -4� -I I 1 ► � 1 _ I r , � 9 ` f I , I I C I , I , t I ■ ■ M MEN SEE NONE 0 ME ONE ME NONSENSE IN M MENEM NONE M ME NONE ME ON IMEM ■� I l� ■ ■ � L ■ u , 1 � ME MEN 0 ME No NONE s ME ON! ME 6: ■ MEMEMEM■ MOMMEMMIMMOM ME MMMMMMMMMEMMMMMMMM MENJEEEMMM mMMMMrMM MENom mmomommmom MMOMM ONE MOMMM ME ON MOEN OMMOMMMEMMOME ME 0 MEN 0 0 MEN 0 MEMEMOMMUM ME MOM MEMEMNEN NoMM EMOMMOMM No 0 ME ONE ME EEO ME 0 ME OMMEME ME ME MOMM ME 0110 mommomm 0 0 MOMMMEMEME EMEMIN MMNo MEMMOMMOMMOM MEN MMMMMM MEMO MMEMEMOMME MENOM No m MOMMINS No .MUEN ME Ml MOMME ME MEMOM mom ME ■emu mm ME ONEME ol Milmoomm 0 M MEN MEN MOEN MEMO MOMMMMS MOMMMME m 0 MEE m m =MEMNON 0 MOM EMEMMEM E M 0 MEN ommim�MMOMMEMEN mmommmimm - MEMO 0mmmmmmmmm� m ME MEMOMMEMEM ME M 0 M MEMEN MEMMEMOMME ME No mom MEME MOM ■u M MOM ME ON ME 0 SEE 0 ON - Ell X, C=g bk� Lvi e, Z- V l -CJ�dC w Veto ° :. /VCR/ �i� �''t �, l D_ �I i•� •�'����:e' �_ �, l �,�` �J(.L/, J � h � _ l I ' _ �# Heating,& Appliance Repair Inc: `;rHe,aiing &Air Conditioning, Design & Installation, Maintenance& Repair n _ Installation .Proposal Prepare& Fora 4 k Gerry O'Donnell 22 Audreys Lane 1/2.4/2006 Ma-srons Mills, Ma 02648 '"e t'E' a"'�-+ra[a;"` �•rt" f� ..�" M,.,q":*kw`t�i s�.fi �'�e rkF? T rC's �: z�.�F°z;. �" a:fi + t EQUIPMENT/SERVICES"TO BE PROWDED.. � �Totdi` , Property Location .9'4 Baxter Ave, H•yarinis Ma GAS PIPING TO ATTIC 'Run gas pipe/supply.-at side of'house&.plac"e test on pipe for. `inspection:=Retum to run gas pipe/supply from,meter set to--existing furnace acid tie:in Coordinate'wi"th the Gas'Inspector(2) inspections,-(1y1 r.test;.(:1'),for final inspection of enure systeme .. INSTALLATION •Move existing furnace to attic and suspend from rafters over drip pan ;with1loat switch Install"'(4) anti-vibration pads under unit. Vent unit with PVC pipe concentric vent to outside.of.Yiouse. Ruri.condensate line down to basement.. Supply (l) Honeywell"T87 thermostat Customer responsible fora l IOV,supply for furnace along with`running of wiring from furnace to thermostat. . DUCTWORK:' Fabricate and install-main trunk'for return and supply air ducts.vvith"26 gauge sheet metal`wrapped with insulation, air supplies and take offs located in ceilings , . of each room with'4-way.ceiling diffusers:: Supply and return plenum will be lined with z acoustical sound liner. f t U)ORCC�Aqe--- IF)SP.eCclop ic" I ' { /ZD a:_LO - dr11e1 f 0,94--, r TV 1 1.1 ,�- � �� � t. - Ppewpeb tea.. A ` 1111V.II Ate F f CCUff V-� I` '. 0�: t y 4. N t Ig6�3y •� ggg tom' co%V-PJ4r,-WNCIOV CW PPCW-RCV to,F% I I�i tip- r��y"iicojl qt 1wl o�vMay `� .�p�l.��p�3� 2_���i��u �g���.;:�p � � a` may.0211p4 �Gi.����.� !�Vl ���'.L:�.�tl�1:L-::�=><~`a� 83�7�„��"�9i'•_t'���,'�L...e"�'y{_ly+a'•.+3`L�'� 'u�9.�-aDU 4. �i9"A3 - �i i$.4�b �L•� q a Proposal Cape Cod Insulation, Inc. 455 Yarmouth Rd. Hyannis, MA 02601 508-775-1214 Fax- 508-778-5735 DATE ESTIMATE NO. 1-800-696-6611 �— — 1/10/2006 3199 Insulation,Gutters,Suspended Ceilings ---��� SUBMITTED TO JOB LOCATION Geri O'Donnell 22 Audreys Ln. 94 Baxter Rd. Marstons Mills,Ma. 02648 JOB SPECIFICATIONS _ PRICE Ceilings with 10",R-30 Kraft faced batts with proper vents installed at eaves. 1,640.00 Exterior walls with 3 1/2",R-13 unfaced batts with polyethelene vapor barrior. Crawl Space with 6",R-19 Kraft faced batts with support rods. CONTRACT PRICE $1,640.00 Chris Legere Proposal is good for 30 days unless otherwise noted.Owner is to keep jobsite clear of any work hazards.Any alteration or deviation from the above specifications will become an extra charge over and above the estimate, All agreements contingent upon strikes,accidents or delays are beyond our control. Our workers are fully covered by Workmens Comp Insurance and we will furnish you a copy upon your request.Owner to carry any other necessary insurances. Payment is due for the amount invoiced upon receipt.Invoices unpaid after 30 days will be subject to a 1 1/2%monthly interest charge. Customer is responsible for any collection costs incurred. Thank you for the opportunity to bid on your project. We do not warrant against and shall not be liable for any damage or injury,including but not limited to mold accumulation. Acceptance Signature