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HomeMy WebLinkAbout0284 BISHOPS TERRACE J . YttE Application number'....1............ ............... Fee................... . ................................. • snPUN'SUM. Building Inspectors Initials..... ... tG39- A`� O MA'S Date Issued......I.. )I ............... ........ ........ r Map/Parcel.......... ........................................ TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: 2-811 81 56-605 T&RR A-C E HY*A11111 S, ` 4 NUMBER STREET VILLAGE Owner's Name: J(,*T"Z C C-W 6(A hIV Y Phone Number-5"a 27-7 7S--/s' 2 � Email Addressla//trh/(enJ4,?4 FV.cot)n Cell Phone Number Project cost$ A.,S®y Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK 0 Siding D Windows(no header change)# D Insulation/Weatherization r� Doors(no header change)# Commercial Doors require an inspector's review 10 Roof(not applying more than I layer of shingles Construction Debris will be going to�J/�/�1�, 6W f� CONTRACTOR'S INFORMATION Contractor's name ANIfRNl WAR YAA1 _ N0151A1 Home Improvement Contractors Registration(if applicable).ble)# (attach copy) Construction Supervisor's License# l 0 /O �i, attach copy)- A N Z Email of Contractor C--p�& R—,1t6r roo P 't' 'C .�oa; Phone number 02 -�7 S-�2� 0 ALL PROPERTIES THAT NAVE STR CTURES 6VIR�i�, L ►��lE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE PERMIT CAN BE ISSUED. APPLICATION NUMBER............................................................ *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 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 pm4.30pm.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 PLICANT'S SIGNATURE Signature,X,dj Date All permit applications are lsj*ect to a btd -ng official's approval prior to issuance. The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 1.4 �VPy` www mass gov/dia NVorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information ��// I Please Print Le ibl Name(Business/Organization/Individual): /1truee;s? S� I �� Address: J City/State/Zip: n L Phone#: 5-©9 -7 Are you an employer?Chec the appropriate box: Type of project(required): 1.tiI am a employer with A.,t, employees(full and/or part-time).* 7. New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in any capacity.[No workers'comp.insurance required.] 8• ❑Remodeling 3.❑1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition. 4. I am a homeowner and will be hiringcontractors to conduct all work on m roe I will 10 ❑Building addition Y property.nY• ensure that all contractors either have workers'compensation insurance or are sole I L Electrical repairs or additions proprietors with no employees. 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12.❑Plumbing repairs Or additions These sub-contractors have employees and have workers'comp.insurance? 13.❑Roof repairs 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 152,§1(4),and we have no employees.fNo 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. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. _l Insurance Company Name: � � LJLQ4't_C:: Policy#or Self-ins.Lic. ©® _/ .6'ly Expiration Date: d g U 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 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 cent' �nde/to ns and penalties of perjury that the information provided above is true and correct. Si a e: - v Date: Phone#: Official use only. Do not write in this area,to be completed by city or town ofj4ciat 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#• Massachusetts Department of Public.Safety Board of Building Regulations and Standards -License: CSSL-106102 . Construction P onsi _rue_lo :�n Su�erviso, Specialty ARMEN SAFARYAN ; a 67 SEA STREET APT A4 HYANNIS MA 02601 Expiration: Commissioner 10/02/2020 &� r Office of Consumer Affairs and Business Regulation 1000 Washington Street- Suite 710 Boston, Massachusetts 02118 Home Improvement Contractor Registration - Type: Individual ARMEN SAFARYAN Registration: 183202 D/B/A COREY AND COREY 1 Expiration: 09/13/2021 67 SEA ST APT A4 ' r_ HYANNIS,MA 02601 Update Address and Return Card. SCA 1 0 20M-05117 ��e lDorrt»an�zranntlf o�'��La;;:rac�rue/(3 Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Individual before the expiration date. If found return to: Registration Expiration Office of Consumer Affairs and Business Regulation 1113202==_ - 09/13/2021 1000 Washington Street -Suite 710 ARMEN SAFARYAN- Boston,MA 02118 D/B/A COREY AND COREY ARMEN SAFARYAN': = r a 67 SEA ST APT A4 ✓.tGL HYANNIS,MA 02601 Undersecretary Not valid t Ignature t� ,4co CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 9/13/2019 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 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 such endorsement(s). PRODUCER CONTACT Ashley Paiva Eastern Insurance Group LLC PHONE (800)333-7234 FAX No: 233 West Central St ADDRIESS apaiva@easterninsurance.com INSURERS AFFORDING COVERAGE NAIC# Natick MA 01760 INSURER AArbella Protection Ins. Co. 41360 INSURED INSURER B Associated Emplovers Insurance Armen Safaryan, DBA: Corey and Corey INSURERC: 67 Sea Street INSURERD: Unit A4 INSURER E: Hyannis MA 02601 INSURERF: COVERAGES CERTIFICATE NUMBER:2019-20 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 A L SUBR POLICY EFF POLICY EXP LTR POLICY NUMBER tMM1DDNYrn IMMIDDIYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE ❑X OCCUR DAMAGE TO RENTED 100,000 PREMISES Ea occurrence $ 9520046441 9/18/2019 9/18/2020 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY 0JEa �LOC PRODUCTS-COMP/OPAGG. $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident) _ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ - NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DIED RETENTION $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICERIMEMBEREXCLUDED? [N]NIA B (Mandatory in NH) WCC50050150912019A 9/18/2019 9/18/2020 E.L.DISEASE-EA EMPLOYEE $ 1,000,0 00 If yes,describe under ` DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD.101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Display Only THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE John Koegel/APAIVA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD INS025rgmdml Rg � R. E y 66 The Roofers " 67 SEA STREET APT#A4, HYANNIS MA 02601 PHONIE 1-508 -775-8240 CERTAIXTEED LANDMARK LIFETENI - ALGAE RES:1STANT ARCHITECVURAL S7YLE RE - ROD II PROPOSAL September 26, 2019 KATHLEEN KENNEY 284 BISHOPS TERRACE EM: kmkbi e2gft-otvmv kle Ni HYANNIS,MA Tel: 508-775-1523 COREY & COREY hereby proposes to perform the following services in a neat and professional manner and in accordance with the manufacturer's specifications and local building codes. Remove and Haul Away All of the Old Asphalt Roofing Shingles (One Layer) from the Entire House and the Shed.Re Nail All The Existing Sheathing as needed. Supply and Install CERTAINTEED LANDMARK AR: LIFETIME WARRANTY, 10 YEAR SURE START PROTECTION, CLASS A FIRE RATED, COPPER/CERAMIC STONES for a FULL 10 YEAR WARRANTY AGAINST ALGAE CONTAMINENT,235 POUND,EXTRA HEAVY WEIGHT, 130 MPH WIND WARRANTY, CATEGORY III HURRICANE, STORM/HURICANE NAILED (6 NAILS PER SHINGLE), MULTI-LAYERED,LAMINATED ARCHITECTURAL STYLE,FIBERGLASS BASED ASPHALT SHINGLES. 7 :,. f7 COLOR: / 5" Supply and Install 8" WHITE ALUMINUM/HICK'S VENAD DRIP EDGE on All of the Eaves. Supply and Install 8" WHITE ALUMINUM DRIP EDGE on All of the Rake Boards. Supply and Install CERTAINTEED WINTER-GUARD (Ice & Water Shield)WATERPROOF UNDERLAYMENT SYSTEM on Roof Eaves & Valleys Under the Step Flashings, on the Skylights and Chimneys. Supply and Install CERTAINTEEDIS "ROOF RUNNER" SYNTHETIC ROOFING PAPER Supply and Install AIR VENT SHINGLE VENT H RIDGE VENT on the Entire Ridge. Supply and Install NEW ALUMINUM& NEOPRENE SOIL PIPE FLASHINGS Supply and Install NEW LEAD FLASHINGS ON BOTH CHIMNEYS Clean and Remove Debris from work area after job is completed. ROOF INVESTMENT ------------- $149500.00 C 0--- R C 0 R " The Roofers ADDITIONAL WOMMENDED WQ;ZK: Supply and Ins W VELUX VENT SKYLIGHT, LACING THE SKYLI ON THE IZARSIDE---------- --r----G-------------------�Xl, 00.00 POSSIBLE EXTRA CARPENTRY: Any Rotted or Otherwise Deteriorated Trim Boards,Plywood Sheathing, Missing Metal Flashing, Side Walling or Any Other Carpentry Needing Replacement will be done and charged for as an Extra: Materials Plus Labor at the Rate of$ 60.00 per Hour(For Each Laborer Involved). PAYMENT SCHEDULE: A Deposit of One Half is due at the Signing of this Roof Proposal and the Final Payment for the Balance is Due Immediately Upon Completion. WORK SCHEDULE: All the Roof Work is Scheduled for Completion Within 90 Days of Acceptance and the Deposits Received are Non-Refundable After a Three Day Cooling Off Period from the Date of Signing. Please Make Checks Payable too COREY & COREY COREY & COREY Warranties the Shingles and Labor for 10 years. CERTAINTEED Warranties the shingles and labor 100% for the First 10 Years and the Shingles your LIFETIME if the shingles becomes defective. CERTAINTEED Warranties the Shingles up to a CATEGORY III HURRICANE-130 MPH WIND WARRANTY. CERTAINTEED Warranties the Shingles to be Algae Resistant for a Full 10 Years. COREY & COREY carries Workman's Compensation and Public Liability Insurance on the above work DATE OF ACCEPTANCE: ACCEPTED BY: WDMITTED BY: KATHLEEN KENf-; A FARY C & A1*_ HOMEOWNER COREY HIC # 183202 CSSL# 106102 TOWN OF BARNSTABLE BUILDING PERMIT PLICATION � A n !_...� � Map Parcel lS/ Z ? � � WW.J « rAlicgion Health Division Date Issued C j Conservation Division '� <. p lication Fe Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address �S �S iti-Pf GE_ Village A41emr7ts ,/ Owner i h;ri0 5 - zrr Address MY B�ShbR5 Telephone ` Permit Request 3eWw1S f�U be ).I V`t r a",( Ki t b"., l n S'&d fleyu A09j ry 444d Cot,,61l s . rr�SC �ev�J �/noldt y ,/2 ice , dc�G( &Ole Square feet: 1 st floor: existing ��5`�?proposed 2nd floor: existing � �-proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size 20,, 0 3 Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family B' Two Family . ❑ Multi-Family (# units) Age of Existing Structure 19-7 Z Historic House: ❑Yes ❑ No Old King's Highway: ❑Yes ❑ No Basement Type: WrFull ❑ Crawl ❑Walkout ❑ Other � s , Basement Finished Area (sq.ft.) 2A0 11 Baserp4nt Unfinished Area(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: #3 existing -new Total Room Count (not including baths): existing 7 new First Floor Room Count Heat Type and Fuel: dGaS ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes M 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: Qd 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 P Telephone Number 77`1. a Z-3 3 41 Address �14 1. et dG License # 6c1 3 7 )b so Ai J)4M 0 �S , �� b Lfe (yQ Home Improvement Contractor# (03734- Worker's Compensation# (XXC5P6T7Q&0/Z011 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO 5+ YdY7S' z's+6/b0 c SIGNATURE 2 DATE 1117113 i ' FOR OFFI.CIAL USE ONLY APPLICATION# S \� DATE ISSUED t MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE s { ELECTRICAL: ROUGH FINAL r ,2 PLUMBING: ROUGH FINAL f GAS: ROUGH FINAL j FINAL BUILDING r DATE CLOSED OUT i ASSOCIATION PLAN NO. f r Town of Barnstable Regulatory-Ser-vices BAhNgrAWNThomas F.Gei[er,Director Building Division . Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www:town.barnstable.ma.us . Office: 5084Q-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section .If Using A Builder as Owner of the subject ptoPY hereby authorize; /YI �.¢ �if 'to act on nay behalf, in au matters relative to work authorized by this building permit 2-915�'to�s f�rr'ac� (Address of Job) , Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is-installed,and all final inspections are performed'and.accepted signature of Own S, e f Applicant Print Name — Print ame . Date QTORMS:OWNERPERMISSIONPOOLS 62012 r zHE l 'Tbwn'of Barnstable . _ Regulatory Services -.. Thomas T.Geiler,Director MAS& Building Division '�rED MA't a '' •. Tom Perry,Building,Commissioner ' 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us . Office: 508-862-4038' . Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER'; name home phone# work phone# CURRENT MAILING ADDRESS: city/town. state zip code`. The current exemption for"homeowners"was extended to include owner-occupied dwellinj6,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 ti 1, supervisor: DEFINITION OFHOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two-family dwelling, attached or detached structures.accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Official on a form acceptable to the Building'Official,that he/she shall be responsible for all such work performed`under the building permit. (Section.109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other. applicable codes,bylaws,rules and regulations: . The undersigned"homeowner"certifies that he/she understands.the Town of Barnstable Building Department mi num inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to,do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor.(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannotproceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure thaf the homeowner is.fully.aware of his/herresponsibilities,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 fon /certification.for use in your community. Q:forms:homeexempt The Commonwealth oflllassachuse& Deparfinenl of Industrial Accidents Office of Investigations , :600 Washington Street . Boston,MA 02111 www.mass gov/dia Workers, Compensation Insurance Affidavit:Builders/Contractors/Electricians/PIumbers Applicant Information Please Print Legibly Name(Business/orgawzation/individuai): fl• ( %(/! r 7��iY lam/ L= 07 C - , Address• 12& f City/State/Zip: hone#:_ 7 Z-`-:-3.3Z Ar project an employer?Check the appropriate box: Typa of (required): 1. I am a employer with Z ' -4. ❑ I am a general coitnactar and I ❑ employees(full and/or port-time).* have hired the sub-eomrac� 6. New construction rs . 2.❑ I am a sole proprietor or partner- listed on due attached sheet t 1. ❑Remodeling. 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 -I 0.E]Electrical repairs or additions 3.❑ I am a homeowner doing an work right of exemption per MGL 11.0 Plumbing repairs or additions myself[No workers'comp. a M§1(4),ana7; no 12.®Roof repairs inmrance mgnir�ed.j t employees.(No comp.insm>snx 13.❑Other *Any applicant drat ehcc s box#t m►rst also 6U out the=don below shosvmg their vmdsts'oampeasa M Policy heotmatioa_ t Hazahmmms vdro submit this affidavit ndica ft dL7 ate do➢og all wod:and drn hie outside wotmckw most sobmtt a new affidavit indreat ng such. tCotrttaMm that clank this ban unni attached an additional shot showing the name nrthe sub ommractm and dwir worLm.comp,policy infncmatioa. ram an employer that isproviding workers comWensation bisurasaeformy employees; informadom Below 6 dhepolicy saidJab site Insurance Company Name:_ Policy#or Self ins,Lic.#: 6V �/ ZDLo 0 f �Y - Bxpiradion Date: /] :"ZQ Job Site Address:. -1 S I'C�MWe =dOmftj City1Sta Mip: l M W Z Attach a copy of the workers'compensation policy declaration page(showing the policy number and exph-atlon 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 nP 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$250.00 a day against-the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for-insursace coverage verification. I&hereby a andpenaides ofperJary that the information provided above is true"and correct Si re: Date: _/ o� 21 2 -33 Z . . O„ ski use only. Do not write in this area to be eonrkted bey CAV or tows officiab City or Tovw Permif/Lleense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4:Electrical Inspector S.PIumbing Inspector 6.Other Contnet Persons , ----MON RACAM-1 OP ID: MD 14�R I CERTIFICATE OF LIABILITY INSURANCE F ATE(MMIDDIYYW) 01118/13 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the poliey(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 such endorsements). PRODUCER Phone:508-255-800 CONTACT Kerry Insurance Agency,Inc. PHONE FAX Scott Kerry Fax:508-240-186 Arc No): PO Box 1945 E-MAIL North Eastham, MA 02651 ADDRESS. W.Scott Kerry INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:ASSOCiated Employers Insurance INSURED R.A.Campbell Enterprises Inc. ' - INSURERB: > Ryan A.Campbell INSURERC: 126 Bayridge Drive South Dennis,MA 02660 INSURER0: 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 MAYHAVE BEEN REDUCED BY PAID CLAIMS. INSR ADM SUBR POLICY EFF POLICY EXP T TYPE OF INSURANCE POLICY NUMBER LIMITS GENERAL LIABILITY EACH OCCURRENCE $ DAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE OCCUR MED EXP(Anyone person) $ • - PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LMNrr APPLIES PER: PRODUCTS-COMP/OP AGG $ POLICY PRO LOC $ AUTOMOBILE LIABILITY BI Ea accident ANY AUTO - BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS - - NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS (Per accident) 'UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR HCLAIMS-MADE AGGREGATE $ DED' I RETENTION $ WORKERS COMPENSATION WCYIMfrS SLIMITTATU OTHER- AND EMPLOYERS'LIABILnY TOR A ANY PROPRIETORIPARTNER/EXECUTIVE Y❑ NIA 009706012013 01/11/13 01/11/14 E.L.EACH ACCIDENT $ 100,00 OFFICER/MEMBER EXCLUDED? 100 00 (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $ , If yes,describe under 500,00 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS 1 LOCATIONS r VEHICLES(Attach ACORD 101,Additional Remarks Schedule,If more space is required) Carpentry Ryan Campbell elects coverage under this workers compensation policy. CERTIFICATE HOLDER CANCELLATION TOWN-01 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Town Of Barnstable ACCORDANCE WITH THE POLICY PROVISIONS. - , Building Department 230 South Street AUTHORIZEDREPRESENTAnVE Hyannis,MA 02601 W.Scott Kerry ©1989-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD j , `^ tsoara ar tsuilmrng Regulations and Standards umeeort ansu€aerasusrs&uasiness Negaiation Construction Supen'isor - ;_kONE IMPROVEMENT CONTRACTOR License: CS-093716 - ` = Registration •163732 Type: = Expiration: *1W2013 -Private Corpo RYAN CAWREL r Rat CAMPBELLENTERPRISES INC. 126 BAYR[DGE DR rz s S DENNIS MA 02660 - RYAN CAMPBELL _ 126 BAYRIDGE DR .SOUTH DENNIS,MA•02660 - y— Expiration Unde�seeretary:* -. Commissioner 04/06/2014 ' n valid for indnn us dul e only License or registratio before the expiration date. U.found rxturn to: Office"of Consumer fairs and Business Regulation lfl Park Plaza-suite 5170 " r . Boston,MA 6110. F �• r m of v wdb t signature n i Y I g 1 31163 1 l 4.,. y WAM oA 1 ar Zl2 32� MEMBER REPORT Level ATTIC,nook Drop Beam �' PASSED 9FORTE 3 piece(s) 13/4"x 91/4" 1.9E Microllam®LVi. Ovem"Lull: 15'3- _ g y A - <S t a 0 77 i� 1 i All bczlons are measured Rom the outside face of left support(or lift m Wever am).All dimemi3ons are horizontal. Rewfts Aetua1'O U adon Mowed Raw1t.. wf toad:core mem(Psiban) Sys em.Flaw Member Reaction(OK) 2847 @ 3" 10041(4.50") Passed(28%) -- 1.0 D+1.0 L(All ns) hkmber Type:OW Beam Shear Qbs 2419 014'1 1/4" 9227 Passed(26%) 1.00 1.0 D+10 L(Ail Spans) Building Use:Residential Moment(R4bs) 10155 @ 7'71/2" 16806 Passed 60%0) 1.00 1.0 D+1.0 L All S 8uildin9 Code;TBC Uve load Defl.(in) 0.405 @ T 71/2" 0.492 Passed tj437) -- 1.0 0+L0 L Ail S Design ASD Total load Dell.(in) 0,630 @ 7 71/2" 0.738 Passed U281) i.0 8+1.0 L All Spans) Delfection criteria:LL(UM)and TL(U240). Bradn(lu):AD compression edges(hep and bottom)must be braced at 15'Y a/c unless detailed odwvAse.Proper anx,h.errt and positioning of� bracing IS required to achleve member stability.. 7. GNAV Reno% t,o"s to&pporft Qbs) rN . V061. A.0 We Repuhed Dead trot T AcoesetrrSCs 1-Stud w�-SPF 4.W 4.50' 1.5V 1017 -)1830 2947 .. 81c�c.ng 2-Stud wall-SPF 4.W 4.SV 1.50` 1017 (1830 2947 &WO9 l •Btod"Panels are assumed to wry no toads applied directly above them and the fu0 load is appfsed the vd6er being dew• TriDtlWry Dead fl WUV-1a, Loa& iaratiW Wroth to90) (LOD)_ coed r )' i-Unitorm(PSl7 0 to 15'r 1Y 10.0 20.0 i Residential-Uving Areas Mantles UK" ATTIC BM Weye111inunP Notes � (ty}StJ5tAJ4ikatf FOCfF5TRy N MTtiI yE weyettae+rser rvarrang that thasMV,of its pioduric w(tl be to accordance with weyertrae+iser precluct design u7terla and published design values: Weyerhaeuser a vressfy discialms any other wanantied-retated to the software.Refer to airrent Weyerhaeuser literature for installation dews., (www.woodbywy,com)Accessartes(Rim.Board,81odarg Panels and Squash Stocks)are not designed by this sotbvare.Use of this sofbvare is M intended to dromment the need for a design profeFsional as determined by the autt rlty having jurioietiwu.The designer of record,builder or framer is responsible to assure Brat this ca6ndatfon is compatible:with the-averali project.Products manufaftretl atlNeycrtraeoser faciaffes are third-party certified to sustainable forestry standards. , The product itoplicatim1rW design bads,dimensions and support hsfwmation have bt"n provided by RYAN CAMPBELL c' i r . OF g o� MICHELE � g c CUDILO STRUCTUR L y No 34774 i ti. dr. (s1STE ¢i Forte Software Opwator ,Job Notes r183/rA20133L00*.03PW' MOW*CWdo, moddicauons to rod Fortev4 0,Q�ign Engine:VS;6 1103 WholeGwdoP E 2S4 BtSHOPS TERR 7. i5001;7i-750t HYANNS MA J mcutlik(fcamcasl ne: } tt Page 1 of 1 TOWN OF BARNSTABLE CERTIFICATE OF OCCUPANCY + PARCEL ID 251 166 GEOBAS'E ID 16253 ADDRESS 284- BISHOPS TERRACE PHONE HYANNIS ZIP LOT 18 BLOCK, LOT SIZE DBA DEVELOPMENT DISTRICT HY PERMIT 424.86 DESCRIPTION GARAGE/DINING ROOM ADDN (BLDG PER 35420) PERMIT TYPE BCOO TITLE CERTIFICATE OF OCCUPANCY CONTRACTORS: Department of Health, Safety ARCHITECTS: and Environmental Services TOTAL FEES: THE BOND $.OQ � Qi► CONSTRUCTION COSTS $.00 i 753 MISC. NOT CODED ELSEWHERE BARNSTABLF, MASS. 1639. BUILDI' VISI BY DATE ISSUED 11/17/1999 EXPIRATION DATE e. �''�� �rl,1 T rA t p� T }� y` .x•ty•��h eYtJvIN ��F td�3_t1.(i:N 1.21l#��-i73-.E - P RCU ID 251 166 GE 3ASE I'll 1625'" A-DDRU 284 BISHOP& i AC9 i�H��ldh ZIP t W`.L' lfl I313C?i.`i> IJ `l.' S FL - DT.3A DU4V1E'f,t1ryMENT Di STRICT RY PER13T 3542fl DESCk.TPT10I "1 2• "U.? 2ACyI+."1.2' 2G"�;lEi'UI � idtz ru" � PERMiT TYPE BADDI '":FTI.3, F#CJI:LP£NG Pj.1;U11`i ADDI1.11T.Ce, CONTRACTOR'S.: ATtBVPZ RCY ISROWN Department of Health, Safety ARCIiITZG'Ts: and Environmental Services T0TAL Fr,I 3S- $1.39.1)0 BOND THE 434 RES ID ADD/t+ CAMV l Pik 1 Vfi`.1 F P * BARMABLE, • � MASS: �0.1 ED Mp►l BUILDING;DIVISI'ON B ! DA'.-..T .S st r,I.) 12/ 1 b 11498 l:X{' I AT,.; ' WATEK` i THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET,ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER TEMPORARILY OR PERMANENTLY.EN- CROACHMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED BY THE JURISDICTION.STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT OF PUBLIC WORKS.THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF FOUR CALL INSPECTIONS REQUIRED z' FOR ALL CONSTRUCTION WORK: APPROVED PLANS MUST BE RETAINED ON JOB AND WHERE 'APPLICABLE, SEPARATE 1.FOUNDATIONS OR FOOTINGS THIS CARD KEPT POSTED UNTIL FINAL INSPECTION PERMITS ARE REQUIRED FOR 2. PRIOR TO COVERING STRUCTURAL MEMBERS HAS BEEN MADE.WHERE A CERTIFICATE OF OCCU- ELECTRICAL,PLUMBING AND M FOR (READY TO LATH). PANCY IS REQUIRED,SUCH BUILDING SHALL NOT BE ANICAL INSTALLATIONS. + CH- 3.INSULATION. OCCUPIED UNTIL FINAL INSPECTION HAS BEEN MADE, 4.FINAL INSPECTION BEFORE OCCUPANCY. BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 1 r -17 i I 3 r 1 HEATING INSPECTION APPROVALS ENGINEERING DEPARTMENT t ;2 BOARD OF HEALTH r OTHER: SITE PLAN REVIEW APPROVAL ;* WORK SHALL NOT PROCEED UNTIL PERMIT WILL BECOME NULL AND'VOID IF CON- INSPECTIONS INDICATED ON THE INSPECTOR HAS APPROVED THE STRUCTION WORK IS NOT STARTED WITHIN SIX CARD CAN BE ARRANGED F, VARIOUS STAGES OF CONSTRUC- MONTHS OF DATE THE PERMIT IS ISSUED AS TELEPHONE OR WRITTEN N! TION. NOTED ABOVE. TION. Jae *�6 f y�5 � t • Y t P E . •�� cn-�' Y . f } I � IN A 'N TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Permit# j - n 1=lealth Division/ Date Issued C 6 �-Conservation(Division l `�`� Fee /✓�I s SEPTIC SYSTEM MUST BE usurer, f' a / INSTALLED IN G®NIPLIAEC Y� �� V,117H . - TITLE 5 = E VI.RO MENTAL COD Aft f , Project Street Address -Village .Owner 7�2 9 / 1 . Address Telephone $ Permit Request OAS a CM W A l� PHA 6 Square feet: l st floor: existing/��roposed 2nd.floor:existing proposed Total new �036 Estimated Project Cost "L C)� Zoning District Flood Plain Groundwater Overlay ' 1 9 Y Construction Type Lot Size , I 6LC_u_ Grandfathered: ❑Yes ❑No If yes,-attach supporting documentation. Dwelling Type: Single Family � pTwo Family ❑ Multi-Family(#units) Age of Existing Structure P Historic House`. ❑Yes O'0 On Old King's Highway: ❑Yes l'lo Basement Type: U( ull UA&wl ❑;Walkout ❑Other Basement Finished Area(sq.ft.) a Basement Unfinished Area(sq.ft): x Number of Baths: . Full: existing new Half:'existing new 0 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 � W � �C�� (, Central Air: ❑Yes No Fireplaces: Existing. . 1 New 0 Existing weed/coal.stove: Yes ❑No Detached garage:Cl existing, new size Pool:❑�exiss' g ❑new size Barn:O existing ❑new size Attached ara e:❑existin 2new sizen�`IP Shed:® ❑new size 0 Other: 9 9 g � existing" �� Zoning Board of Appeals Authorization ❑ Appeal# a Recorded❑ Commercial ❑Yes ❑No If yes,.site plan review# Current Use Proposed Use L , / BUILDERt INFORMATION Name' ' Z C, N Telephone Number -' 5 Address -_tit V1- #1 L: License# ��5 �� �Z Z-C.),2a Z_ Home Improvement Contractor# /ZCvSe0 ( Z/0 Worker's Compensation# C " 0 � G.31 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DAT FOR OFFICIAL USE ONLY PERMIT NO. ,` �:'� 'r - ,.�•. - DATE ISSUED _ . . a `. r. _ r - • ♦ } MAP/PARCEL NO.'. rj -VILLAGE 'ADDRESS, �� � , { OWNER"" DATE OF INSPECTION: } _ FOUNDATION. FRAME (/� l ti` `• ,> , INSULATION" FIREPLACE ELECTRICAL: ROUGH' -. FINAL _ t PLUMBING: ROUGHt FINAL r GAS: - ROU'`GH;, FINAL F _ FINAL BUILDING DATE CLOSED OUT ` + -ss `'• � -, -.$ ' ; - r ASSOCIATION PLAN NO. r- I�� � ;1�,� -- -� 21 2 - IL �,ol SCAIE:I/ - I/ ARRROVED'BY: OR BY 1 DATE: REVISED N -Z -- ORAWINGNUMBER kM . 1z 2-5cs SCALE:�/ - I / APPROVED BY: DR ByRao JJ DATE: _IZ REvISED _ DRAWING NUMBER !7 Yw i Gear Ge(u.a 3ox3oxio' comic-�a-0 €! s` _ � Y �oc�nci�.�7ioa �j�g-•� _ SCALE:II - I APPROVED BY: DRAW-ZN BY DATE: - REVISED 1L— 26— DRAWING NUMBER N - 3 .j>(12 Glar :I IN I :1 i '! • Y' SCALE:1/ _ ' AVPROVED BY: ORAL BY DATE: REVISED DRAWING NUMBER (1 MAScheck COMPLIANCE REPORT 13 Massachusetts Energy Code Permit # MAScheck Software Version 2.0 Checked by/Date CITY: Hyannis STATE: Massachusetts HDD: 5973 CONSTRUCTION TYPE: 1 or 2 family, detached HEATING SYSTEM TYPE: Other (Non-Electric Resistance) DATE: 12-28-1998 DATE OF PLANS: TITLE: COMPLIANCE: PASSES Required UA = 105 Your Home = 97 Area or Insul Sheath Glazing/Door Perimeter R-Value R-Value U-Value UA ------------------------------------------------------------------------------- CEILINGS 340 30.0 0.0 12 WALLS: Wood Frame, 16" O.C. 504 19.0 3.0 27 GLAZING: Windows or Doors 79 0.400 32 DOORS 42 0.350 15 FLOORS: Over Unconditioned Space 340 30.0 11 ------------------------------------------------------------------------------- COMPLIANCE STATEMENT: The proposed building design represented in these documents is consistent with the building plans, specifications, and other calculations submitted with the permit application. The proposed building has been designed to meet the requirements of the Massachusetts Energy Code. The heating load for this building, and the cooling load if appropriate has been determined using the applicable Standard Design Conditions found in the Code. The HVAC equipment selected to heat or cool the building shall be no greater than 125% of the design load as specified in sections 780CMR 1310 and J4.4 . Builder/Designer Date MAScheck INSPECTION CHECKLIST Massachusetts Energy Code MAScheck Software Version 2.0 DATE: 12-28-1998 Bldg. Dept. Use CEILINGS: [ ] 1. R-30 Comments/Location WALLS: [ ] 1. Wood Frame, 16" O.C. , R-19 + R-3 Comments/Location WINDOWS AND GLASS DOORS: [ ] 1. U-value: 0.40 For windows without labeled U-values, describe features: # Panes Frame Type Thermal Break? [ ] Yes [ ] No Comments/Location DOORS: [ ] 1. U-value: 0.35 Comments/Location FLOORS: [ ] 1. Over Unconditioned Space, R-30 Comments/Location AIR LEAKAGE: [ ] Joints, penetrations, and all other such openings in the building envelope that are sources of air leakage must be sealed. Recessed lights must be type IC rated and installed with no penetrations or installed inside an appropriate air-tight assembly with a 0.5" clearance from combustible materials and 3" clearance from insulation. VAPOR RETARDER: [ ] Required on the warm-in-winter side of all non-vented framed ceilings, walls, and floors. MATERIALS IDENTIFICATION: [ ] Materials and equipment must be identified so that compliance can be determined. Manufacturer manuals for all installed heating and cooling equipment and service water heating equipment must be provided. Insulation R-values and glazing U-values must be clearly marked on the building plans or specifications. DUCT INSULATION: [ ) Ducts in unconditioned spaces must be insulated to R-5. Ducts outside the building must be insulated to R-8.0. DUCT CONSTRUCTION: [ ] All ducts must be sealed with mastic and fibrous backing tape. Pressure-sensitive tape may be used for fibrous ducts. The HVAC system must provide a means for balancing air and water systems. TEMPERATURE CONTROLS: [ ] Thermostats are required for each separate HVAC system. A manual or automatic means to partially restrict or shut off the heating and/or cooling input to each zone or floor shall be provided. HVAC EQUIPMENT SIZING: [ ] Rated output capacity of the heating/cooling system is not greater than 1250 of the design load as specified in sections 780CMR 1310 and J4.4. MISC REQUIREMENTS: [ ] Refer to 780 CMR, Appendix J for requirements relating to swimming pools, HVAC piping conveying fluids above 120 F or chilled fluids below 55 F, and circulating hot water systems. ----NOTES TO FIELD (Building Department Use Only)------------------------- l _ The Town of Barnstable • snxxs'r M • 9� ' `0�'9. Department of Health Safety and Environmental Services ,epepMv�0. _ Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 Ralph Crossen Fax: 508-790-6230 Building Commissioner PLAN REVIEW Owner: Map/Parcel: � r Project Address: Zia IJ� i a. c)P Builder: Y. The following items were noted on reviewing: r r Please call 508 862-4038 for re-inspection. Inspected by: "P I J � Date: q:building:forms:review The Town of Barnstable Department of Health Safety and Environmental Services Building Division 367 Main Street,Hyannis MA 02601 Office: 508-862-4038 " Ralph Crossen Fax: 508-790-6230 f Building'Commissioner Permit no. Date " AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. P i/Type of Work: 1`7 Estimated Cost J Q® Address of Work: S tj L.3 /Owner's Name Clsa 1X6ate of Application: I hereby certify that: Registration is not required for the following reason(s): [-]Work excluded by law ❑Job Under S 1,000 ❑Building not owner-occupied ❑Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby ply for permit as the age f owne Date ntractor Name Registration No. OR Date Owner's Name q:forms:Affidav -.- The Commonwealth of Massachusetts " == Department of Industrial Accidents .. 600 Washington Street -"-- � Boston,Mass. 02111 '— Workers' Com ensation Insurance davit i - name:. R �2e V OZJ tO_'J location: �I 0 a`-'�� � �6 ' city OM N3--i— j'�u [(—cc � ► 1 q ` phone# Q� 7T^ Z ❑ I am a homeowner performing all work myself. ❑ I am a sole rietor and have no one workin in capacity %IV:m //�%%/%/%/Z/Z//////////�/////////////%////%%%////�� %%%%%%%%%%%%%%%%%%%//////%%%��%%%%////%%%%%////%%%%%%////////%ffIFIlZ�/�,D✓//AI an e.. pravidin orkers'compensation for my employees working on this job. :::............:...... . .: Q.::.::::.:::::::::::.::::.:::.:::.::::::::.::::::::.:..: :.;.:.;:::.;:.;:.::.:.::... :: an :name..: .:' .: :::<>;: .;:;. address ..:>.:: i... :: .::> O"O cttw^ t - .: .. I. phone.# .. :... ......;•:::,;;:;- }:_.;. --2::;::;::;:.::: I. � insurance:co.>:;:.I >;.. � ?j::::::.... .. :.` - ::<: `.:>><:'`:: cy:#" .: !, >:�w !,:::::.:;:`.0 ❑ I am a sole proprietor,general contractor, or homeowner(circle one)and have hired the contractors listed below who have . the following workers'compensation polices: .. camany name. _:. <:>::>;;:::::»::>;::;:.;::;;::.;'::::; o :'...:.......:::.::::::::...:::.:::::..:: ... . address ; ..,.::..:...::. :>`<> .: ..::::... ::t<>::" : >: ::.:....:.......::::.:.....: .......... ...... ::•.....:::.... ....,..........:.........................,............ .........,,:.:::::::..... .:. :::::............................................ . . ....:........ ::,..........:.........:::::...:..:..::.::::::::::..::::.:.:..... . ,'.-..<.. ,..:;:. ............... ::.;:.:;.;:.;.:.... .....::. .:.::.:.::. ..... X. rTr011e'# : ;' z>i i> <>' > >> 2` <» >`»><> ::: <:>`::><:> ::: itv:>. o ?i:<:iiii:isi%v:ii:?iiii:^'Y+:j}::ii:!<::iii:}isii?is ii:^i::'::i ::Y^iiiii:iiTiii?:?Jiii:iiij::}iiii:::L'iiii;:i}i??iii:.:.! ::::i?i:?:}}i�i:ii:::i:iii::i:::::..;.:ii .....h fi$iiii:::v:•'.r ::}.ryiii iT":LYi:•::3� .�.1::<:•:::.:�:...::::::.� vnl:A:4ivi-'•:,'vi�ii:'r:4T:<!: .. ,: :::......:.............:w:.�:v.�:. : W:4::Sri::::::.: ::iii:i:...:::::::..........................:..........::................................v........r....v. ...........:.�:::...}::::::.�::.....�::::::w:-v:.., X. esnrance..ca.. . ............... ..... .:::.... ._ o1#cv:#.. .:. ,;::::.;'.;:.:... ..::.:::::::. .:;:.::::>.:,:.::.:...::.;';;::'; anv name:. ;<::>::::>:::.>':>:: . :.•.:::..:.....:..:.. coma ::: ":::".:::... ....... :.;:::..:..;... ..............-xx % .:;::...:::;:.}:::::::;::.:;:.... :>: ... ,: . atidre3s.. .'...;.:::::.::.: ".;':: :: :............. . ...................:........ . ....... ....:.:_.:...: ........... �:..:.:. .................................. .....................:.::::::.:::..:::....:. :::.::::::::.::. ... :.:.....::::: ............................ :::.::X.:.:;:.:.:::..:.::::::::.:..::::::::::::::n ..::.....::>:;.>.<:»>::::>:: % :� :.... nsntance:ca.. .:....:..:.,...... 1. ,_ olicv.#• ...:. ...::..:::::..::.:::}>.:: x.:::::::...::::.:•..:<.::.;:. 111111111111111111111111 Faflme to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to 51,500.00 sailor one years'imprisounient as well as dvfi penalties in the form of a STOP WORK ORDER and a fine of 5100.00 a day against me. I undetstaod that a copy of this statement may be forwarded to the Office of Investigations of the DU for coverage verification. I do hereby certify , pains and hies of perjury that the information provided above' and coned 1 / —� - 9dr Signature Date Print name Phone# 111111 official use only do not write in this area to be completed by city or town official • city or town: permittlicense# ❑Building Department . ❑Licensing Board ❑checkSimmediate response is required ❑Selectmen's Otnce . ❑Health Department contact person phone#; — ❑Other Ormd 9/93 PJA) Information and Instructions ' Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the "law", an employee is defined as every person in the service of another under any cow- 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 o: the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receive: trustee of an individual,partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state or local licensing agency shall withhold the issuance or renews: of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting- authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and supplying company names, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the`law"or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. City or Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. The affidavits may be returned io the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any questions. please do not hesitate to give us a call. The Department's address,telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents Of(tCe 01 Invesugallons 600 Washington Street Boston;Ma. 02111 fax#: (617) 727-7749 phone#: (617) 7274900 eat. 406, 409 or 375 Tahb.l=h(eenfsned) XK PceseriptHe Packages for One and Two-F=4 ltesideatW Bnitdlngj Seated with Fond Fads MAXIMUM MINIMUM G aaag Glazing Ceiling Wall Floor 8asem� Slob �+og ArealCx) U-valuer R valuer Rvalue' Rvdu2 Well Petimma E lode' P=kge �` 1Gvaluet ltrvalae' 5701 to 6500 Headag Degtee D&W Q 12Y. Q40 38 13 19 10 6 Normal dt 12% OJ2 30 19 19 10 6 Normal S 120A 0.50 38 13 19 10 6 83 AFUE T 158A 036 38 13 2S WA WA Normal U- 13% 0.46 38 19 19 10 6 Normal V 13% 0.44 38 13 23 WA WA 83 AFUE W 13% OM 30 19 19 10 6 SS AFUE x` 18% 0.32 38 13 23 WA WA Normal Y Is% Q42 38 19 25 WA WA Normal Z 12% &42 38 13 19 10 6 90 AFUE AA Ir/. 0.50 30 19 19 10 6 90 AFUE P ADDRESS • C OF PROPERTY. a r-w to ,,C S UARE FOOTAGE OF ALL EXTERIOR WALLS: Q ,./; SQUARE FOOTAGE OF ALL GLAZING: 4. %GLAZING AREA(#3 DIVIDED BY#2): S. 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-080303a ppen x Footnotes to Table J5.7_1b: Glazing area is the ratio of the area of the glazing assemblies (including sliding-glass doors, skylights, and basement windows if located in walls that enclose conditioned space,but excluding opaque doors) to the gross wall area, expressed as a percentage. Up to 1%of the total glazing area may be excluded from the U-value requirement. For example,3 ft of decorative glass may be excluded from a building design with 300 ft of glazing area. =After January 1, 1999, glazing U-values must be tested and documented by the manufacturer in accdrdance with the National Fenestration Rating Council (NFRC) test procedure, or taken from Table J1.5.3a. U-values are for whole units: center-of-glass U-values cannot be used. ' The ceiling R values do not assume a raised or oversized truss construction. If the insulation achieves the full insulation thickness-over the exterior walls without compression, R 30 insulation may be substituted for R-38 insulation and R-38 insulation may be substituted for R-49 insulation. Ceiling R-values represent the sum of cavity insulation plus insulating sheathing (if used). For ventilated ceilings, insulating sheathing must be placed between the conditioned space and the ventilated portion of the roof. 'Wall R-values represent the sum of the wall cavity insulation plus insulating sheathing (if used). Do not include exterior siding, structural sheathing, and interior drywall. For example,an R 19 requirement could be met EITHER by R 19 cavity insulation OR R-13 cavity insulation plus R-6 insulating sheathing. Wall requirements apply to wood-frame or mass(concrete,masonry, log)wall constructions,but do not apply to metal-frame construction: s over unconditioned aces such as unconditioned crawls aces,basements, The floor requirements apply to floors o spaces( P or garages).Floors over outside air must meet the ceiling requirements. `The entire opaque portion of any individual basement wall with an average depth less than 50%below grade must meet the same R-value requirement as above-grade walls. Windows and sliding glass doors of conditioned basements must be included with the other glazing. Basement doors must meet the door U-value requirement described in Note b. 'The R-value mquirements•are for unheated slabs.Add an additional R-2 for heated slabs. • If the building utilizes electric resistance heating use compliance approach 3, 4, or 5. If you plan to install more than one piece of heating equipment or more than one piece of cooling equipment, the equipment with the lowest efficiency must meet or exceed the efficiency required by the selected package. 'For Heating Degree Day requirements of the closest city or town see Table J5.2.1 a NOTES: a)Glazing areas and U-values are maximum acceptable levels. Insulation R-values are minimum acceptable levels. R-value requirements are for insulation only and do not include structural components. b) Opaque doors in the building envelope must have a U-value no greater than 0.35. Door U-values must be tested and documented by the manufacturer in accordance with the NFRC test procedure or taken from the door U-value in Table J1.5.3b. If a door contains glass and an aggregate U-value rating for that door is not available, include the glass area of the door with your windows and use the opaque door U-value to determine compliance of the door. One door may be excluded from this requirement(i.e.,may have a U-value greater than 035). c)If a ceiling, wall,floor,basement wall,slab-edge,or crawl space wall component includes two or more areas with different insulation levels, the component complies if the area-weighted average R-value is greater than or equal to the R-value requirement for that component. Glazing or door components comply if the area-weighted average U- value of all windows or doors is less than or equal to the U-value requirement(0.35 for doors). 43 q 9:10 ao 15 LOT '19 ~ B 'HSE: Col4C o-,ZB4- PAD= �` __- 1_ I.,?p, 54 ,O =_-- 24 3'=1- nl _° , - >:� - LOT , C\Q 41 LOT 17 , RE,S. ZONE.- "RC. This MORTGAGE INSPECTION Plan is For Bank Use Only FLOOD ZONE. „C TOWN: _EF:, . IVI, REGISTRY OWNER: THOMAS _F._ &_KATHLZE�V _KELYIVFY _ DEED REF:: �TF� 2�'�7 -- -----BUYER: -REF& Aycf ------=---------- DATE: PLAN REF: -Z5306 B SHEET_Z___SCALE:1"= 30' __FT, I HEREBY CERTIFY TO .�''A. �Q�D6NKs ��Sl�T�9�Z' --- SUCCESSORS AND/OR ASSIGNS__,THAT THE BUILDING ��N OFq> YANKEE: SURVEY. SHOWN ON THIS.PLAN IS LOCATED ON THE GROUND. AS SHOWN AND THAT .ITS POSITION DOES ____ CONFORM or PAU�; q�y�, CONSULTANTS TO THE ZONING 'LAW SETBACK REQUIREMENTS OF THE R A. 40B (SUITE. 1) TOWN OF BNSTAB MlwF16Ti'iClN INDUSTRY ROAD ------------=AND THAT IT DOES_ NOT N0. 3'4�n LIE WITHIN THE SPECIAL FLOOD HAZARD " �'��, ,p �'�+ MARSTONS MILLS, MA. 02648 AREA AS S'HOWN.;ON THE H.U.D. MAP DATED 'r fCIST��;k�a CO unit -Pa el' .250001 0005 C �/.�9�1��_ '���"�r o��°� TEL 428-0055 �' THIS PLAN NOT MADE FROM AN FAX 420-5553 PAt�L. A. 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C W yV,PGE �h'kO01, GOl �. _d.x% 2 rfD .. .. nu�rc :3o'x.3o."xron ax(PT.JIU.S.u/y,SeAL coac.rnof . - - -'- 4-0" F/16, . d"eONC- bARAGF FRAL.1/�!� 4-ECTfUN GOB F cA 'rC,5. -D.AA4 ...PRDOF Lo J �� G'RsrDE .. DI AII/JG.KOOM TAAAWCr SEC770�3 ..8 a�X 6857$EL.bwA....._._.._. .. c aPxB Rz..D¢aR_........ ........ _"....... .. - F 45.944�-l8 G �(a06.vR1.✓.K g1e _....._ µ a aQ• - e..n� GKAt.J.I.SP�cE j,Xy, O Gonir.. n,5 ' a� o � / G12Y "CO aCG0. ��G 30Sc.30"�lOs O� LO �a a7 ,yv, OIG14 ��6 V60I to sow'^ �vetjr , 6 ALE LR ?'Lill �ounrDlknn.J Pia ' qir I Q Oyyb � o TA -I}= 8 .eDl - 9e404 VF4w I G 'L S - _ K_ (a all �. UD2A cl {' — .. 'FI/RST LIDOR. PLAN .. _ s EEI -� n I M L a II' RZ HT ALE YA-'rtn . £A2 ,F Lr- - FM . LFtT ELFVA-Y/Dn� ". TP-6 tJ7- ELAV.4Y/0nJ t r)MIJT ELEVATON . /}DDIT>D.J..i4f�NS Fac KEAAE, RESIDeNcc try 90,4¢na v4touE-JaNufaJ Sd8•??�-667y AM My 4,%01w1 . 6LDR-. - y LT t pm(,�E,CO4 . SOG we t3T ax.Id21VL�fsj � ° W ax rO RA'G)ER/! -PdX.f e/L'Oe. d Ix SF aP�AI5E+_-„F., b LFlgx..aN O2T-'4DK b _ Io a 3O�•� _ gE V�RIG 0._.y7D 1 (Mh ,N4..GH 4�no JE ALUM GVTrErywSbn3 - _ a ax8 ttD2 I)a pua. Ix y TR/."I 6 /b"OC Ix S.IXf.L CR5.-13 Y -F- 7 Y J-UD L _ W�CS"TT,k/. 3S.rRE.S r' Iia Ex.yr. SHOE. FQOrJT.C.LAP.BDy. 4"7.-XU,r- . . IX 8 FAj_G.l,_4_tl'OPy/T h� R P � � � •� fEEL8..JX.7.AEA R-W/ .M(..AO LA b5Aa. - .... - . N- - Soa EL � Dx P6x_. -..FFf17ilA•1 c w 3vccE, y3.•ax.raGec( _ _ , .K...:. DE. ' Tl �/h'zoaG. cgs .. ..d.x 8' ND2. Z ou�rG P' •3o'k.3o."icr0"aX6?r-.51 L.L5.GjpeAL (ge1G.MDf baRAG FRA AA/d bL'GTeN GONT F G 5. DAMP...PRbDF _ �,cLor..� GK>A'DE /. GI AIrJ[. 1200M TRAM I.J L+.5ECT7O� - $..._nLusaacrC............:... .. ........ - o�.Y4!G..__........_.......................... ... .... .. ... - _ _ :- .. D �V .o" u�rtpoF a epr oG6L VE VF e �? . oel = ' LL(o. .a Cal \ / FAR v i ti r R ' DELETE I � as x r 9i 0 clavvt,,<a a5° 4'xa' i ° pf2 sT nn02 Pi-,aN L_ a e-In",- ® *a O 4-d'HivN P'2o�c. a .E �o . - - 9-3X toG12Y /3'/a"DAY,.coL. G 3ok3o' COW, A'Df co aT d N�b� 6 x8 .L°P�p _o 5�0o a3°✓,Nv�E �/i'. �, a w•�i� Nat} l�FCOAn LId2Qf PLAA) The Commonwealth of Massachusetts AV .. -_:�:� Department of Industrial Accidents Olficcoflny8502908S g 600 Washington Street Boston,Mass. 02111 Workers' Com,pensation Insurance Affidavit name: location dn' nhone# ❑ I am a homeowner performing all work myself - -- - ❑ I am a sole ro rietor and have no one working in any ca acitv _, aclt� ❑ I am an employer providing workers' compensation for my employee's DEPAR,IMENT OF PUBLIC SAFETY comnnnv name: CU1iST.R OI RV SOR LICENSE TIDN SUPE I 6ir.address: ° ber Ex Tres: hdate: dim P r ��� I3 C'ti���� �5� •02J12J2000 021121159^ city n ReS-trxFc�d Tn 08 - 3 Insurance co. n ❑ I am a sole proprietor, general contractor, or homeowner(circle one 34 HORATIO IN have ;. CENTEflVIILE, MA 82632 the following workers' compensation polices: '-�,}. _-e - - --- --_---_--- • comaanv name: address: dtv phone#:;'..... > ... .::.. ..::.:... insurnn[e co. Oilty# f,{� C�o�wneo�eu d /�aaaac%udelQ . ..' .. .,:.�.:.::;:..:. :><;:::r.:`�. .:rY ACTOR camnanv name: " 0 IMPROVEMENT VEMENT CONTRACTOR Registration 126560 address: Type - INDIVIDUAL Expiration 06/21/00 dtv: phone#c "'. ALBERT R. BROWN hunrance co. :;>: _ ::.;:<;:;:.;•'... ::..>:;;::; <:,.,;:..;:: s.;.:-.;.:.. olicv# 34 HORATIO LN E R V I L L E MA 02632 Failure to secure coverage as required under Section 25A of MGL 152 can lead to the Imposition of cam ADMINISTRATOR one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a One of! copy of this statement may be forwarded to the Ofilce of Investigations of the DIA for coverage vetilla I do hereby certify under the pains and penalties of perjury that the information provided above is true and coned Signature Date _ Print name Phane# oMCW use only do not write in this area to be completed by city or town ofnew city or town: permit/Ilcense# ❑Building Department ❑Licensing Board ❑check immediate response b required ❑Selecanen's OtIIce ❑Health Department contact person: phone#; ❑Other (mum 9/95 PJA) TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION r M Map Parcel Permit# j (p Health Division C61b-gciq LM el 11 '(�� Date Issued q ( a- Conservation Division ` / hoo rye 1 1 2001 Fee Tax Collector e 9 �' l� a�5 1 01 4 Y— Treasurer ' q11 T ZUvF9� Y7'-, o �e 1u4 MUST SE. Planning Dept. Date Definitive Plan Approved by Planning Board 's"° ��.`b'�w �9�L 5 Historic-OKH Preservation/Hyannis Project Street Address 2 9 9 B.I a yi d p S E 2� cdtc Village �`t-��{N►� S Owner Illowits ' 6-RiL-E+3 KENrq6 Address y :&SHaeS �72maG(� Telephone .0 8 7 7S—/SZ�Permit Request il C3oyt IZ(4\ayli(� P& Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Valuation /T ey) ., da Zoning District Flood Plain Groundwater Overlay Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family Z Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes U11110 On Old King's Highway: ❑Yes Qeo Basement Type: @-Fu'-ll- ❑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 3 new / Total Room Count(not including baths): existing 7 new First Floor Room Count to Heat Type and Fuel: 411as ❑Oil ❑ Electric ❑Other Central Air: ❑Yes 0'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 BUILDER INFORMATION Name Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE / DATE 0 // / l y r FOR OFFICIAL USE ONLY PERMIT NO. DATE ISSUED MAP/PARCEL NO. -� r'fl r. # ADDRESS VILLAGE OWNER , • a:r:_ DATE OF INSPECTION: FOUNDATION a. FRAME INSULATION FIREPLACE R ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL i GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. rt The Commonwealth of Massachusetts Department of Industrial Accidents - Office ol/firest/gatioos _ 600 Washington Street ' Boston,Mass. 02111 Workers' Com ensation Insurance Affidavit ffiffiffEffiffinEmp T146mA location: Z 8 C4 131 S LL P S _ 'm7�A/./nJi S ,phone# ,�drf- 7 7cityT-/ t Z 3 ❑ I am a homeowner performing all work myself. ❑ I am a sole proprietor and have no one worldn in any ca�acrtv rr // ///i///%'r// //%//,� /O/////////////////''r����'" °°° ��°✓r//////1� % //////O�'r//////%%%////%%///�%%%%/%%�/�%///%///O/�//�%�%%: din workers' compensation for my employees working on"this job.: Iam an employer providing..:.:.::....:...:.:.::.::: .:; : .:.:.:;.:::;;:::'::> :;:::;:<::::;:":;;:<.:;;:.:<:::>::>,::::>:.;::::;. com inv name. one#:;;. ;::<::>:>;:.:;::::: �:,::«,..::_:;:.;:.;. ..:.:.:... ..... ... . . . :::.::...:.. ............. :::;::>:«.:;::::::::: wsurance,co:: am a sole proprietor,general contractor, or 'gown (circle one)and have hired the contractors listed below who have co ensation polices:folio w mP .... ...... .P :.::.:.::::::::::.....:::::::.::.::.:.;.<;.>:<.;,:::.:.............<: :;.. the ................::.:.:::::. :.... ..........,:.:::::,...............,,:.:..:::.:........ :,::.:::. ......:..:. ::::..............::. :::::.......:: ..:::::::::.:::......:::::::::::. {, aff V. #� ns na !b i) ........................ ... AC ' �aatfre f :if:::i{:i;::•::vi:vi:•ii;{?�:;i?%' ;':;:�j;}:':;i: ........................::::::::{:.:i ivi::.�.�:::::•::n•.�:::•:.�:::::i::::.{:;;isji::ji:::?�ii:::ii'�i:�ii��r:�ii:�>'-i:�:::i?�: S •%:•�' C M a X. ............... �:.�S?�:>.t:?::ri::ii;:;:;:>::?"iif`:?;t::t: �t:�:3:j:�ii:i:•i:i:::r :�:ij;:'�v�r:��`iiT:•s�•'tii;:`;:i;iititititiF:::�'j::�,'.':�:: .0..::..::....:..n..n..:::::::..::..:•......�:..>:ri:ii:ii6::i{^:•ii}::ivi:{•i:av:x;�:4'•i:{{:rv::aa.:.::.:.. :::::•::a::•�•�:::,�:::::::::::.'{:isi::tiii`:�i:v:a+riiiiii:•iiiiiiiiiiiiiiii:4i:::G:v:•:ii:iJi::`:{�i::�i:i.:�iw�i: i s• n :..::.... ....... .. ...:.::... ...... ...::: do :::...:.:............................. :..:........:::::......... ... ....:..:...,...........::..:... ......:.::................. ... ::........::::;...... ... ......,.::... .................. >::::::..........:::..:... ...... ..:.:.... ................::•...........:.�:.�::::::::: :::a:•i:ii....•:.y :':. ..gin.{:•}:•:::ice ii:t.iX:S!:•:i Ji.:-:ii>.:j},i'j;: i:S•::.::: under Section ZSA of MGL 152 can lend to the imposition of criminal penalties o[a line up to S1,SOo.00 md/or Failure to secure coverage required e yam,imprisonment as wen as civil penalties in the form of a STOP WORK ORDER and a fine o[5100.00 a day against me: I understand that a on copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification I do hereby cerd under the paw mid penalties of perjury that the information provided above is trru and correct e srgt 1 Date 09 - J' Print name �^%� i /�c.`�`• Phone# 56 tf 9 '71 /-r Z 3 - official use only do not write in this area to be completed by city or town oMcisl rrndttlicense# ❑ ceding Department city or town: ❑I,icemmg Board ❑Selectmen's Office ❑checkifinnuediste response is required ❑Health Department contact person: phone#; ❑Other UcrAed 9/95 PJN Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers'uciomthpeenssaa comder pensation r Msac a of as service employees. As quo ted from the "law", an employee is defined as every person in the of hire, express or implied, oral or written. is defined as an individual, partnership, association, corporation or other legal ent ', or or the recer two Or mver or Of An employer deceased the foregoing engaged in a joint enterprise; and including the legal representatives of However the owner of a trustee of as individual, partnership association or other legal entity, emp yemployees. house of dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling another who employs persons to do maintenance, constriction or repair work on such dwelling house or on the grounds or building appurten thereto shall not because of such employment be deemed to be an employer. MGL chapter 152 section 25 also states that every state.or local licensing agency shall withhold the issuance or has enews of a license or permit to operate a business or to construct buildings cove in thra a rye uir d. Adonwealth for any ditionallYpnert�� , not produced acceptable evidence of compliance with the insurance� ���for the performance of public work until commonwealth nor any of its political subdivisions shall enter of this chapter have been presented to the contracting acceptable evidence of compliance with the insurance requirements authority. --------------- Applicants ' compensation affidavit completely,by checking the box that applies to your situatim and Please fill in .he workers hone members along with a certificate of insurance as all affidavits may be supplying company names,address and p of insurance coverage. Also be sure to sign and, submitted to the Department of Industrial Accidents or�that the application for the permit or license is date the affidavit The affidavit should be returned Should Y�have any questions regarding the`yaw"or if you being requested, not the Department of Industrial Accidents• to obtain a workers' compensation policy,Please call the Department at the number listed below. are required or PE City or Towns Please be sure that the affidavit and printed davit is c legibly. The Department has provided a space at the bottom of the affidavit for you to fill out is the event the Office of ors has to contact you regarding the applicant Please Invest ti be retluu�{n be sure to fill in the permit/license number which will be used as a reference number. The affidavits may the Department by mail or FAX unless other arrangements have been made. you in advance for you cooperation and should you have any questions. The Office of Investigations would like to thank 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 0mce of Investigations 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone #: (617) 727-4900 eat. 406, 409 or 375 Fig rqy, The Town of Barnstable MAM• ,�ttrtsrest.e. . g Regulatory Services i639' "�EontP't°' Thomas F. Geiler, Director Building Division Peter F. DiMatteo, Building Commissioner 367 Main Street,Hyannis MA 0260.1 Fax: 508-790-6230 Office: 508-862-4038. HOMEOWNER LICENSE EXEMPTION Please Print DATE: O / �I D `�i����s ��-I)_V JOB LOCATION: Z S y village number street /7 "HOMEOWNER": /N6Ml�( r /lC� � S�l� �I7��SZ3 7S/3ad name home phone# work phone# CURRENT MAILING ADDRESS: s�i9 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 ermit. (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 prose es and requirements. ignature of�Homeot�e ��� 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:EXEMPTN ell �0.s_,. 'sy�t�.r t.,fr'! ' ♦,♦ rf r,. /� �t�6i"',}F'�r{ �€� ��III' tt a , �d •\' 1 ♦ dr }: erg .y t'i Rs i r r.t �� iltt ,.,Y/t1 p• +► 7 Ak � � - ` �, .r �, P ♦ t<�- .r ��; '�r^p`..� a '�%� sr !ti6 }�'�1 t ffff, �, I �'�� �. , t •.t iv 1r i�,;.' r r ' + `. ,'�I r t / 1Ar; � !' II '�•� _ � � 'v r,c- �- 's f1�r>r � ���-.c t !(i r i � . _j` l�y. f - + a k t♦ • /.�Ar t t�,7 l,,'�\^. .��`dfJ't � It ,'p+� r � .Y.le' � _ �A \ J s ♦.. )�)` � -.��.---._ .. 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DESIGN WINNER r • sit T - 3e 4 VIRTUALLY � � SELF CLEANING � �- ... _ G POOLTM q »� - � ,,,,, x ` ". •4 �S:r ��r�:p'� � E k S f } � � - - REMEMBER...You can 1 '11 r` v -9-1-1 351 -�T__1 7. u � is the largest builder of pools In every New England state.Beware of imitationsf SURFACE SUCTION CLEAN 7_PooITM from Gibraltar Pools Corp.at 1-800-USA-SWIM.Trust the name and company that _a,ATER RATE ib FILTER 7 FOR EXTRA VALUIEI M. *. .� � i �Cl�'1A s� '.r• A. %i!�' Via.., ` • ♦ • x- B017ON DRAIN SUCTION "Free Backyard'Survey.for„Information,&Details '',` ' x; '., r ,y '- *' ,'a,; M• _ ABOUT •W • I .^.c' �� t' U� to "i` r.. ' • w a' *• .� 1iF" `t % + Yj 0'U-' We Participate BBB (eA •�• a w � ` 7��•,u A Custome,r Assistance Prog am of ,># the smess Bureau Inc. M JCS,f w_a. ,+� .. AS SEEN'IN ��Y" "^ r^Yr� -.Ck�yr fr e'°• ft'1td'.•Y i `"r¢ '` e ¢ y � r :� r�'r+i�. ,w�'' ,ry � °�'� y"��v X!}a ,`�r�.t i w t,:l ��v,`w •��T+�: � � ..wF�c �sa a ' y�,` I i. rv�":�' `+- FR kK'h y� F r �� ��� } � r� ��'��r�Y`�^y a t.�y +k � *�i �� �x� ��'_ K`�`•� � a s� WYy�� � t J _ t tl E. r i �• x �I AAA Ar 40 fflo t •,/ 'A A N TIO L b " INSTITUTE a 5" mat• j IS':;, ii f', ty�s' =" "� ..cam.• rip w `� ��^ `' � ^ '" ... w^Y ""� ) �#+F+°�, '` *`+' at'',.r '*t�������r fit ,, .. ._nR. dew .. • ...... +t"s rl�5f ,,._. ��i' w ♦ d �Y 1 �:Y4�.- t� - v '� '�'�''"�Y`i,' Sa^�Y � ir�' '�..r 4 d�r� �i^aj r leth +;w��rC�r+ �� Ar• vtiY (wr �� �1{Ur% �i +fitr•a't r y.rq" 'Y�,;.. .h^,�.,.'Y• °�/:#:, E Lti'"^'` yiy.l r ii3 Z`T`t;.4°4 r t a }awti. �rza)Y wvY t �*,tir" , y'trl#. " Il:i-lt' ,�il`�Vrr �at "- iN ftp41l�l� 0 % �t 14 U-1 ` fill 1 ',. z�•c z+'t: � 02 Q � Misr t i q t AY I CERTIFY THAT,. THE FOUNDATION CERTIFIED PLOT PLA N l� SHOWN ON THIS PLAN IS LOCATED ON FOR THE GROUND AS SHOWN HEREON AND 284 BISHOPS TERRACE HYANNIS, MA. THAT IT CONFORMS TO THE MINIMUM LOT 18-LCP#25306B BUILDING SETBACK REQUIREMENTS OF THE TOWN OF BARNSTABLE. PREPARED FOR ROY BROWN •° �yam,...,.---• , 40' SCALE: 1" = JANUARY 11, 1999 TEyE vu u�: = Weller & Associates 1.645 Falmouth Rd. -Suite 4C Centerville, Ma. 02632 ) - a: (508) 775-0735