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HomeMy WebLinkAbout0205 BISHOPS TERRACE���� �is/�a� �Ya� � 7are- r Application number................/ .........ESI .........(.. t fs 7�J.......................... Fee..................... ............... 9.. S � ass SEP 2 6 2019 Building Inspectors Initials.. . . .......................... 6 TOWN OF BARNUABLE 1 Date Issued.:...T:as ....... i............................ Map/Parcel........:::...... ..::........................................ TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: \-S ht�vs o t`r,9. NUMBER STRE T VILLAGE Owner's Name:. oW\ Q SO `(l Phone Number Email Address: Cell Phone Number Project cost$ �� o Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize �j���' q 2 O to make application for a building npei ' accordance wi 780 CMR Owner Signature: Date: Q TYPE OF WORK ❑ SidingWindows no header change)# . © Insulation/Weatherization ( g ) ❑ Doors(no header change)# Commercial Doors require an inspector's review ❑ Roof(not applying more than 1 layer of shingles) Construction Debris will be going to G, CONTRACTOR'S INFORMATION Contractor's name Home Improvement Contractors Registration if applicable) # 1 y 1-A (attach copy ) Construction Supervisor's License# (attaph co y) mom; .C-o Email of Contractor e, V C\ V\\V& Phone numbed ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT. YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION.NUMBER..........................................................1.. *For Tents Only* Date Tent(s)will be erected Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X. X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one:this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with the location(s)of each tent Fuel source being used LP tank 20 lbs. or> Yes No____,if yes,a gas permit is required. Natural Gas Yes No ,if yes,a gas permit is required. If food is being served at.your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval. *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number 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 required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT'S SIGNATURE llSignature Date a0 Allpermitapplicationg eresubject to a building official's approval prior to issuance. A ' The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street M Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly n Name(Business/Organization/Individual): Address: G� �v COL City/State/Zip: ar \e.V� (y� . �LF'h e#: 6� a -� �T1 Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with- 14 4. ❑ 1 am a general contractor and I mployees(full and/or part'-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees- These sub-contractors have g, ❑Demolition workingfor me in an capacity. employees and have workers' Y P tY• t 9. ❑Building addition [No workers' comp.insurance comp.insurance. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LE]Plumbing repairs or additions myself. [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑Other comp. insurance required.] *Any applicant that checks box#I 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. tContractors 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. ID Insurance Company Name: Policy#or Self-ins.Lie.#: �'� _� � Expiration Date: Job Site Address: 1 S 1�U�S �r NC�� City/State/Zip: of �. Attach a copy of the workers'compensation policy declaration page(showing the policy nu ber 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 ve 'fication. I do hereby certify, r t pains and n ' of perju that the information provided above is true and correct. Signature: Date: 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,constiuction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),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 i or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington.Street Boston,MA 02111 Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia AC<>RD C'ERTI CAT-E-OF LIABILITY��NSURANCE- " DATE(MMIDDNYYY) 09/25/2019 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-OFINSURANCE DOES NOT CONSTITUTE-A CONTRACT BETWEEN THE ISSUING NJSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT. If the certificate holder is an ADDITIONAL INSURED,.the policy(ies):must:have ADDITIONAL INSURED or.be endorsed. If SUBROGATION IS WAIVED subject ta•the terms and conditioris;of the policy;certain policies may require an endorsement: A-statementon- this Certificate does not confer rights to the ceredccate hoer m heu of such endorsement(s).. PRODUCER :'CONTACT" Judy Pashko NAMComplete Benefit Solutions fAfC E�E,n (800)584 5470 FAX No (413)538-5761 Arc • ; Ar One Carando Drive,.Suite 1 SAD RAIL ipashko@completepayro)lsotufions.corn INSURER(S)AFFORDING COVERAGE NAK #' Springfield MA O1,104 INSIJRERA. AmGUARD 42390 INSURED _.INSURER,B_. NorGUARD 31470 LeMieux Construction Inc. INSURER C: 40.Pleasant Bay Road. INSURER D: INSURER E: East Harwich WA 02645 INSURER F COVERAGES CERTIFICATE=NUMBER: CL.191902625 REVISIOWNUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE.BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD X. INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERT)FICATE.MAY BE ISSUED.ORMAY PERTAIN,THE INSURANCE AFFORDED BY T.HE.POLICIES.DESCRIBED.HEREI:N 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 POLICY EFF-.. POLICY EXP , LTR INSD WVD POLICYNUMBER MM/DD MM/DD LIMITS. COMMERCIAL'GENERALCIABILITY EACH OCCURRENCE 5 1;000000 +:; CLAIMS•MADE _aX.' DAMAGE TO OCCUR - .':.PREMISES(Ea occurrence) �5_50,000 MED.EXP(Anyone person) s 5,000 A LEBP912977 05/15/2019 05/15/2020 `?PERSONALBADVINJURY S included GEN'L AGGREGATE LIMIT APPLIES PER:. GENERAL AGGREGATE S,2;000,000 X POLICY F i PRO- LOC - - - PRODUCTS-COMP/OPAGG 1 g :2,000;000 OTHER: S . AUTOMOBILE LIABILITY - - .COMBINED SINGLE LIMIT :5 Ea accident ANY AUTO -i BODILY INJURY(Per person) OWNED SCHEDULED BODILY INJURY(Per accident) S AUTOS ONLY AUTOS -HIRED NON-OWNED ;-PROPERTY DAMAGE5.- AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LJAS OCCUR EACH OCCURRENCE 5 EXCESSLL46 CLAIMS-MADE 'AGGREGATE S ` LIED RETENTION$ - - $ WORKERS COMPENSATION PER AND EMPLOYERS'LIABILITY STATUTE ER YIN 100;000. ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT 5 B OFFlCERIMEMBER EXCLUDED I N NIA LEWC988043 111021201E 11/0212019 (Mandatory in NH) E.L DISEASE-EA EMPLOYEE iS 100,000 If yes.describe under 500,000. DESCRIPTION OF OPERATIONS below. - - E.L.DISEASE-POLICY LIMIT S DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORO 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOJJLIIANY OF THE ABOVE DESCRIBED•POUCIESBE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE.DELIVERED IN Town of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. •200 Main Street AUTHORMED REPRESENTATIVE Barnstable MA 02601 � ©1988-201'5ACORD CORPORAT[ON. AIFri'ghts reserved. ACORD 25;(2016/03) The ACORD name and logo are registered marics ofACORD d Commonwealth of Massachusetts ' Diwsion of Professional Licensure 'Board of Building•Reguiations and Standards Constrv,-06A rvisor CS-082000 .: 9 res'08117/20Zq PHILIP J LEMI 6 l i 46 PLEASA ' Y Rfti HARWICH MA O Commissioner tom K, 9/25/2019 My Registrations J � i a 4 This i9s an official application of the Commonwea"of Massachusetts ' _(http://www.mass.ggv) ' Office of Consumer Affairs&Business Regulation(http://www.maLs.gov/ocabr/). Home Improvement OCnbBCtt r:PnXjrai71 +, (http://mass.gov). ail ,R ist a ar �s i • Your company Registrations and/or Applications with'their statuses are displayed in thelist;below. i • To manage or view any Registration, click on the appropriate Task button. ` • To register a new company as a Home improvement Contractor,click the Start New Application button.74 i Start'New Application (/HIC/Register/Ctaec]List?contractorid=G&applicationld=0) i (contractor CSC Re ...-tration Effective -Ex iration.A<, r cati ... re ._.. ... t # r � P pp cation ;AppticationCreate :Task -Name -NurnberStatus :Date Date Type Status Date . w.} �. _,_.. .... . _..,,�.�.. s...... ':Registration: PHILIP LEMIEUX 149495 Active 02/21/2019 02/20/2021-:Renewal 01/25/2019'Managi r lssuedf i Registration { 4PI IILIP LEMIEUX`149495 `:Expired 102121/2017 02/20/2019 2eapplicahon, 02/21/2017 ManagE Issued t f ;PHILIP LEMIEUX; Registration: 149495 -Expired` '03/02/2012 03/01/201 4ZenEwa! ^03/4"t/2F312:14 snag 3 ,CONSTRUCTIONI Issued..PH-ILIP LEMIEUX ? ;Registration _ i 149495 -Expired 01/13/2010�01/12/2012Renewal 01/12/2010 Manag( jCONS.RUCTION issued iPHILIP LEMIEUX{ -w Registration �149495 _Expired 12129/200912/28/20'I1'Renewal 12/28/2009=ManagE ;CONSTRUCTION Issued ! '1PH1UIRLETJ1EUX Registration 4149495 `Expired '02/05/2008 01/12/2010 Renewal 02/04/2008 Marag i +CONSTRUCTION' lssued I =PHILIP LEMIEUX 1 InitiaE Registration l 149495 `Expired 01/1312006;01/42/2008 :01/12/2006 Manag CONSTRUCTION Application Issued - k ©2019 Commonwealth of Massachusetts E l i https:#hic.oca.state.ma.us/HIC/Register/RegList L TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Ict Application# C9_C07 0( (10_' Health Division Conservation Division Permit# Tax Collector Date Issued Treasurer Application Fee go Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board �k/ Historic-OKH Preservation/Hyannis Project Street AddTqpn.p ss Village Owner ASP ' Jn� �ess Telephone Permit Request -A Square feet: 1st floor:existing proposed 2nd floor:existing proposed Total new---'- Zoning District Flood Plain Groundwater Overlay Project Valuation� 0 Construction Type ,l �l. �C _. Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. �21 Dwelling Type: Single Family ® Two Family ❑ Multi-Family(#units) Age of Existing St211 e Historic House: ❑Yes ❑No On Old King's Highway: ❑Yes ❑No Basement Type: ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) `� Number of Baths: Full:existing d new Half:existing new Number of Bedrooms: existing new Total Room Count(not including baths):existing new First Floor Room Count Heat T n Fuel: Type and ue Gas ❑Oil ❑Electric ❑Other Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use $Aee BUILDER INFORMATION C,, Name Telephone Number 50S l 71 Rbir_. p 9Address 4 License# Home Improvement Contractor# Id�� ~ Worker's Compensation# 1,q ALL CONSTRUC ON DEBRIS RESULTING F OM THIS PROJECT WILL BETAKEN TO SIGNATURE DATE 3 1O 7 FOR OFFICIAL USE ONLY .PERMIT NO. DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME �. I � -�-7 4� INSULATION ®rG Z+,f '9--O 7 FIREPLACE r' ELECTRICAL: ROUGH FINAL' PLUMBING: ROUGH FINAL, GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT '. ASSOCIATION PLAN NO. 1 r 0 �Ya � o -y t ✓/ce-Pa�ma.:.�alU �✓�r�aaaadw BOARD OF'BUILDI'a REGULATIONS License: CONSTRUCTION SUPERVISOR Num6ei'"CS 071488 2. j 15x�res' 552#�L007 Tr.no: 15103 Rust&&" AN" + : s JOSEPH A BU`Tit - PO BOX 616 " SO DENNIS, MA 02tifi0 /J I Commissioner lie T�amv�xaix:�,!/`7'�ac�waetla " Board of Building Regulations and Standards HOMEIMPROVEMENTCONTRgCTOR Registratiolug n:`.128086 Expiration 2J22l2009 Tr# 127876 TYPe Individual JOSEPH A.BUTLER JOSEPH BUTLER 91 SOUTH STREET SOUTH YARMOUTH,MA 02604 Administrator J i TOWN OF BARNSTABLE LOCATION AO S SEWAGE# :;00 VILLAGE 14W14WWf`1C ASSESSOR'S MAP&PARCEL 'INSTALLERS NAME.&PHONE NO. SO 2 75- F774, SEPTIC TANK CAPACITY 1 OOC> LEACHING FACILITY:(type) PIZ.4 06(L (size) Z X 1 3 y� 2 !4 _ NO.OF BEDROOMS. OWNER i E C 3 4-2k (t%JC-/N PERMIT DATE: I1 Z./��(�(� COMPLIANCE DATE: 2 U Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility(If any wells exist on site or.within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet FURNISHED BY f . . `1 tic 0)5 Z T, 1!3,200'. 2--9 PN FkM: 32z Thossg wocde Irsurarca Agency TO: 1-508- 6 -A549 FAGE: Col OF 002 OP ID B DATE IMIUD01YYYf! ACORD. CERTIFICATE OF LIABILITY INSURANCE �s-2 01 03 07 PRGDuc1 1 TMIS CERTIFICATE IS ISSUED AS A LIATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Thoamas J igoods � , HOLDER.THIS CERTIFICATE DOES NOT AMEND.EXTEND OR P.O. Box 2940. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Worcester H& 01613 Phone:508-755-5944 gax:508-791-9841 INSURERS AFFORDING COVERAGE NAIC S ROURED lu_!!IM a Travelers Insurance ��y t[iRSIwFF R ( 4 nathaa-La is Joseph Butler I"' WorceeterrUh 01602 IPlSlA'ee"F E: COVERAGES THE POUCI_S OF INSURANCE LISTED BELOW HAVE BEEN ISSUED 70 THE INSURED NAMEDABOVE FOR THE POLICY PERIOD iNDr.ATEO.NOTWITHSTANDING ANY REOWP.EMENT.TERN OR CONDITION OF ANY COM7RACT OR OTt Et DQr!MMENT NIITH RESPECT TO WHICH T-08 CERTIFICASE MAY BE ISSUED OR MAY PERTAIN.THE ENSURAAICE AFFORDED BY THE POLICIES DESC;UMD HEREIN IS 912JECT70ALL THE TERMS,M(CLUSIONS AND COND M44S OF SUCH POLICIES.AGGREGATE LIIMTS SHONM MAY HAV-c BEEN REVJCED BY PAID CUUMS. POLCY"imest DATE M= DATE(l1Bi�D LtEilTS LTR TYPE OFNSURA►10E �$500000 FA('H�:i 91P.P.Ft.i P OBiERAL L)ABMY g g CCR,QAERCL>LC�EI9FFPiLUREILI-Y 680-8816C774 11/30/06 11/30/07(lea+t;Es:E3 C a; $3000_00 .:ALIAS MKE CCC'P i Mir E ';.may or-?ersx.) 0 FEP Iw�L E t,e ;vzN: jssoc000 J r ( uEtEFA:JCe'F.-fi'E G 3000000 tithLa_�tctC=atJA1AFK&'-FhK: I ItOL'Ui1- �t�,yr�c�1- j31000000 gy�pp-. I --- LOC i ( f AUTOMOBILE LU169ITY i OhqPETi SIPlC1E UL.4i i I �aa:ci4x11 I 3 2i A,UT_ , Al l CasAifl:AlT0.4 &KILT Iti,A115' .r, .Pa pEr;on! I SCl�IAS,AJfdS 1 1 i iPe mti� I 7,414E7 AXIS ( 1. I I e ceEPTY U+."3'. .P9'aGpdrml! 1� GARAGE LIABLITY { AIJtC�!!Lt-E4 SrCcOEt:T j MY AUIC I � (rT ER TI-All EA FCY.1 i NlT4'AL(- EX ELLA UABLRY I F C.H ;i A IR4•Ft t t j _-- , 1? ^J L=ws� AbtiREiAIc „i f IL :` , i I 5 (T DELUCTIBLE � — if - PETENTK" S YI( S COTWN Ally I -i�Y LIMR� Ek EMPLCYEWUABJUrT i$SIP LQOTE B1xP I E E4:r+.f•_t(NrJtt�-- I iJil PIi6PR1ETD�PARTtlEF/E%tECIR VE E L D.S=,5E-:-:A=-MPL6•:E? S i?FRt 'nR.1FA'IAFi'i ---r---'-- 't`ve;.d�:r::Prwilrr.� ( ELLaS=-G!7LIC`_,Td:T J!'ut.SL f'f;CV151�lc G?a'Qr. OTHER s 1 , 1 I OESO>lPliOMt>FOPERATIOMBfL06ATI=fVEBCIE8!EIIGLl1S "m1DEDETY tT/SPECWLPR61fISfOM: Alomm =wmmTION COVER m III omaTica HILL BE PROVIDZD U11DBR SEPARRTI; COVSR BY Tm "slew RISK CA m1m. CERTIFICATE HOLDER CANCELLATION 819GttD ANY of 71IE AEOY2 DEtKRIBED POLICES Be CAIICIB.tW BEFORE THE EXP6tATION DATE THEREOF,719E Iy8UWG ei$LM t YrLL BOEeAVOR TO MM 10 DAYS WR'rM •i0 TIE CERTFMTE 40 DEtt NAM®TO THE LEFT.GItT FALCfiE TO DO 89 C14ALL UPOW 110 OBUGAUM ORLUMM OF ANY KW UPON TILE @!SURER.ITS AGEMS OR RL3ESE TAMBL 0 ACORD CORPORATION I M DATE@IM�DTYY) :.. ' PRODUCER ` ONLY 'AND CONFERS NO RIGHTS UPONRTHE(CERTIFICATE ;iOI�l.S'7 wOO?S Ilia r.0 HOLDER. THIS OOVERAGGEEFAF CERTIFICATE BYTHE POLICIES EXTEND OR O c� PO BOX 2J40 COMPANIES AFFORDING COVERAGE SOY WORCESTE:R mr, Q161 COMPANY A v INSURED Ct71IPANf I.AP-N, JCHATHAN :v RIJTi.F.R, B JOSEPH I;RA SAT.T3ROR{ HOI4F3 COMPANY 453 CHANT.•".FR ST. Ci 77CiRC.FSTFR NIA 01602 ODWANY D -'COUERA6 ;, , THIS IS TO CERTIFY THAT THE POLICIES 0=INSURANCE uI;TED BELOVI HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR .HE POLICY PEAl09 INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERRA OR CONDITION OF ANY CONTRACT OR GTFER DOCUMENT WITH RESF=CT TO WHICH THIS CERTIFICATE MAY BE LSSUED OR MAY PERTAIN,THE 04URANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXLUStONS AND CC*L1•,10NS CF SU i POUCIE-I.tMrM SHOWN MAY HAVEBEEN REDUCED BY PAID CLAIMS. POLICY EFFBCRVE POLIV onniCi LIMITS LT TYPE Or INSURANCE POUCTNUMBER QATF(�DIhYY) DATEtLWDDtVV) TR GENERAL UAB(UTY (}NrHa A zt w:A l r COMMER-0AL GENERAL LIAB'I- FROOL Cr*4"Pn)P AGO S CLAIMS MACE QOCCLF. PER"SONA-3 AL><I.INJURY S FA(:H01X;I1RRi-Nf:r S VW�EaS3 JONIRA'.7ORS?FYJ7. RJE BWAGE;Any wit G.n) c i• MEE,.CK'ENSE(Ary one;arson) AUTOMOBILELM,BIUTY U CoMiliNEOSiNGLE S LIMITANY AUTC ALL OWNED AUTCti Ht a)d v IN a It Y (Per Pawn) SCEMLEDAUTOS BGD i-RED @ INJInY 1S (Pert Asu.�cr1) Nr)N•f PMIM-0 At it a LFIMNFHIY I)A.1AAi:F S AUTO ONLY-EARSIDENT IS GARAGE UABIUTY OT,F-R TNANALTCONLY ANY AUTO E4a/k.CiCEAT EACH•?'0W-1-ECE S Exams LIABILITY AGGREGk16 rRO'IVER1t-ANUMBPEUAF3W' .S;AlI:1:1hYi@ttliti WORNER'SCOMPENSATION AND 16; 1 EI-l7-Oli 10-07-07 A EMPLOYERS UABIL'ITY, EACH ACCIDEYT S i(%�•^3CL Hi P,{t)VHd-()IS/ IXGL DSEASE-70LICT LNHT PARTNEFryf*C:j-IVE DISEASE-EACH EN=V YEE 5 Inc. 1 09RCERS ARE: v ,EKCL THER D LOCA C NSIS E ITENIS THIS PLACE IC C-& T= ICF E ISSO O T:E i FR r C ;1 WO J C"� 11p Gr 4"ANCEtikJ4TiOt� SHOULD ANY OF THE AUOVE DESCF40ED POUMES BE CANCELLED BEFORE THE E[pIRATICN DATE THEPEOF, THE ISSUING COMPANY WILL ENDEAVOR TO YWL 10 JAYS WRITTEN NOTICE TO THE CERTIFICATE rIOLDER NAMED TO THE . LEFT. BU' FAILURE TO MAIL SUCH NOTICE SJIALL_IMPOSE NO OBLIGATION CR UABBM OF 4NY IUND UPON THE COMPANY.ITS AGENTS OR REPRESENTA'.IYES. AUTHORIZED REPRES@ffATWE J D'CG+RPORA110N'180 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 Le 'bl Name(Business/Organizatiotdlndividual): . Address: City/State/Zip: d?Q,� Aid 0/ Phone.#: 50i 7lb Are you an employer?Check the appropriate box: Type of project(required):. 4. I am a general contractor and I 1.� I am a employer with ❑ 6. ❑ ew construction . employees(full and/or part-time).* have hired the sub-contractors 2.El 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 employees and have workers' working for me in any capacity. 9. ❑Building addition [No workers' comp.insurance comp.insurance.$ required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their l 1.❑Plumbing repairs or additions right of exemption per MGL repairs co 2 Roof myself. o workers 1 . insurance required.]t c. 152, §1(4),and we have no . - 13.❑ Other 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. '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. Iam an employer that is providing workers'compensation insurance for my employees. Below is.the policy and job site information. Insurance Company Name: y� � Policy#or Self-ins.Lic.#: Expiration Date: 1-61 le) ___Tit - Job Site Address: o� / � � 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 Investi ations f the DIA for insurann cover e verification. I do hereby er fy un er the in d al ies of perjury that the information provided above is true and correct. Si afore: Date: /L Phone#: �� 7 � 7 rIssuing e only. Do not write in this area,to be completed by city or town official. own: Permit/License# uthority(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 o,on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for,the performance of public work until-acceptable evidence of compliance with the insurance requirements of this chapter have been presented'to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers'compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit.or license is being requested,not the Department of .Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete'and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permitllicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"I:he 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 1-977-MASSAFE Fax#617-727-7749 Revised 11-22-06 www.mass.gov/dia oF�HE ro,,, Town of Barnstable Regulatory Services " BARNSrABLE, ' Thomas F.Geiler,Director y Mnss. g' �A s63q. �0 Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 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: � � Estimated Cost 5 Address of Work: Owner's Name: CV1 Date of Application: I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded by law ❑Job Under$1,000 ❑Building not owner-occupied ❑Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS.FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c.142A. SIGNED UNDER PENALTIE4 OF PERJURY I hereby apply for a permit as 'ag nt of the o er: �f' ?ijeL Date Contractor Name Registration No. . OR at er's Name Q:forms:homeaffidav pp s� ♦ �r ; t ff ..f i ✓ �..rx 4, lY f - °FINE ra,, Town of Barnstable Regulatory Services "r'"M N. Thomas F.Geiler,Director 16;9. A`0 Building Division� g Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder subject b'er of the suproperty as Own J /7 hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application for: . 9 / Da60 / (Address f Job) 1 Signa of F Date l Print Name J Q:FORMS:0 WNERPERM ISSION k �. i- � v ! � � � 4\ y /„ �. I U �/ (`J/ ., S � 1 ,/ (' ` ` � ,y �� • �� - ash✓�9�:G. �� . j Aesses'sor s map and lot number ypF TN E Tp� Sewage Permit number .............................:...................:...... li BAWSTADLE, i House number " q MAB6 pp 039. \e0 .w JOWN , OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO ..................... . .V-41, ....................(/..;........................................................ 0 .........................................:. TYPE OF CONSTRUCTION ..........................:::.................. "t .......... Sf..........I9.A.pp-- TO THE INSPECTOR.OF BUILDINGS: The undersigned hereby applies for a permit according `to the following information: Location ............ Q.. ....... (-:�.... . . ...�:...........L.4m. ........................................................................ • ProposedUse ............ ,...... .....J�.. . ........................................................................ Zoning District .....................:........Fire District .............. ... .............................................. .... Nameof Owner ..................Address ................................... ............................................. ofBuiler . . . :.Address ......Name . . ... .......... . ........................:..................................................... Nameof Architect ......................................................... ......Address ............................. ..............:.......................:........... Number of Rooms ..................................................................Foundation ................ . —... .... ............................................ Exterior ........................... .............................................Roofing ........... , A . w!......� k...............I......Interior ..................................................................................... Floors ................... � r Heating ........................................ ............ ..... ..........Plumbing ..... ........ ...[.�� 1................................. ......... Fireplace . ...........................�..._:................................... .Approximate Cost ......�..C�.a............. ........... .......... ...... .... .... ..... Definitive Plan Approved by Planning Board._______________________________19________. Area ...(.. !!..........:...`...........:. ' Diagram of Lot and Building with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH 12, OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS 4 1 hereby agree to conform to all the Rules and Regulations of the Town of Barnstable,regarding the above construction. ti. Name . ..... ..... Construction Supervisor's License x .- a.. LARSON, JUDY r 24916' Build S e No ................. Permit for ........I........... Accessory to Dwelling M .................................. .................................. ... ! Location ..205„ Bishop„Terrace ....................HYann ......................................... Owner .......!iay..LarsQx?.............................. ' Type of Construction ......................... ' .....•........................................................................... t� ' 9 ~�. ' -. .. • t ' • , Y r r 'Plot ............................ Lot ................................ 7 - Permit Granted Apri 1...5.!... ......19. 83 ,; I Date of Inspection. Date Completed ...... ....19 76 - ► esso 's map and at number ............ . ............................ .ry <, II QyOs TM E?��y Sewage Permit number ........................................................ Z BARIMBLE, i House number .................................................................:...... soo . 11 s 'E0 UP Ord TOWN OF BARNSTABLE BUILDING INSPECTOR APPLICATION FOR PERMIT TO `Ulti... . TYPE OF CONSTRUCTION ..........................................................�' ............................................... ......... .. 1 ...5 ..........19 k TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location .................... cl:�-.......... .� .... . ....rs......:.....- t.' . :e-~'.......................................................................... Proposed Use .............. ��.... ...J�... ......................................................... .... ZoningDistrict ............................ .. ..... ..............................Fire District .............. ......f ....................................................... Nameof Owner ..................Address .................................................................................... Name of Builder .......... ...... .........� !.5. £�--� .............Address .................................... Nameof Architect ..................................................................Address ..............................:..................................................... Number of Rooms ..................................................................Foundation ............. i�.f�"' ................................................. ExteriorPAL.............................................Roofing ........... .J�..: �X.............................................. Floors .............�. ..... ..f/'`......................Interior .................................................................................... ...... Gf Heating Plumbing .................................................................................. ............................ f �—Fireplace ..................... ................................. Approximate Cost ............55.Q.)............................................. Definitive Plan Approved)by Planning Board ---------------_______ �2'.. - -------19----- Area .......................................... Diagram of Lot and Builiding with Dimensions Fee SUBJECT TO APPROVAL OF BOARD OF HEALTH OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of thejown of Barnstable regarding the above construction. Name . . ...... �.'. Construction Supervisor's License ...................................... LARSON, JUDY A=251-196 W*o .24916. . . .... Permit for ...Build. . ....Shed.. .. .. .... ..... .. .... . .............. ` + Accessory to Dwelling ............................................................................... Location ..205 Bishop Terrace ............................................................. ' Hyannis ............................................................................... Owner Judy Larson ................................................................. Type of Construction ..Frame ........................................ ................................................................................ Plot ............................ Lot ................................ t April 5, 83 Permit Granted 19 Date of Inspection ....................................19 Date Completed ......................................19 T r' TNET��`w TOWN OF BARNSTABLE i BABBSTUL$ i o M a,� BUILDING INSPECTOR aY ' APPLICATIONFOR PERMIT TO ................................. ....... ........................�.................................. ............. TYPE OF CONSTRUCTION ...:( 41........AO.V-... l. . ......................................................................... ......L. ..��?...................19.7 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a/permmit according to the following information:: / Location .....l al........V..Ld..........131,r..000e. ....................................2��L�.........../l � . Proposed Use11 .. .....4L .................� Zoning District x ..Fire District .........y �/�/� . .. ...... ........ ........... ................. Name of Owner .!.i!l. h../.�1. ..�..:....L/, 1�.�!:'Address ................................�� w +Gy �� ...�� ............. . ........ Nameof Builder ....................................................................Address .................................................................................... i , It ' Nameof Architect ....�............................................................Address ......................../.......................................................... Number of Rooms .... ................... .....Foundation ../..C/... K� .4 .1............ � Exterior '.Roofing ... ...... ..... .............................................. / C Floors ....Q/.��.............................................................Interior .. .. ...//�1...:..:�..��........................................ Heating ......�J..zv.......,. ................Plumbing .....1......f..... ,/J ............................. Fireplace .................Approximate Cost ... ..0. ................................ .... .. ....... nn Difinitive Plan Approved by Planning Board _19 e e -7 Diagram of Lot and Building with Dimensions ' LL-O � � Q M m. 0 F- '71 z W > W � 4i.1 co zQ0,\ o LL L- w 0-1\0 0 n w a - m � Q LU WM 00 sa. J J W < I�- c _ co U) fY (f) \ G Z (w FW- W 0 0d ¢ w:2 v) O Z� w`U n Q X J \ xj LLJZ., 361 2 � � ¢ o ZE U = W I--) J O U) ? Qc� U0 Jro � I hereby agree to conform to all the Rules and Regulations of the Town of Sir _ carding the above construction. V,4"&4 i ' QName . . ................ � Dacey, �Alliam E. Jr. 1583* one story ' No ................. Permit for ....................................single family '. --'���7���..�.����.—�...'����..�________ �j5 Biobopa �erraoe---- on --'------------------- / .............. ---'—^-- ........................................ } � W�II�a� E. D", Jr. Owner ---- e3r-------''��� �-- --- \ / | ` Type of Construction ..................frane............. � ! --------------------------' ! / Plot ............................ Lot ........#5O_____.. | | Permit Granted -- .l8........... g 73 ' Date of Inspection .. .. --------]9 Dote Completed PLE `J PERMIT REFUSED ~_> ---------------------.. 19 ----------------------.---.- ----------------------'---'- v ----------------------.---.- . '---------------^^—'--^~'—`—^^' � Approved ................................................. lA ^ -------------'----^----^^--- ' . ' ----------`--------------^'- U � U