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HomeMy WebLinkAbout0064 COMPASS CIRCLE (D �l Ccrr,pass in TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map v Parcel`-' ��' j� ( a° Application #20 BARNSTA�BLE, Health Division � ;r;j s f Date Issued Conservation Division J Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board DIVISm Historic - OKH Preservation/ Hyannis Project Street Address r;Y (S-yn12 ss C[m)C Village Owner Address 3:r%L Telephoned 2y��Gi�y Permit Request Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family U/ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing —new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use --- -- Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name �Mike MeC ,-thy Constr»ctinn Telephone Number PO Box 52 Address West a...___.. MA 02670 — License # Cell (508) 280-6964 Home Improvement Contractor# Email Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO O, SIGNATURE DATE I/II�y FOR OFFICIAL USE ONLY APPLICATION# r DATE ISSUED G MAP/PARCEL NO. t ADDRESS VILLAGE F f 1 OWNER f DATE OF INSPECTION: FOUNDATION C. I FRAME-- INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL c PLUMBING: ROUGH FINAL i GAS: ROUGH FINAL FINAL BUILDING r, DATE CLOSED OUT ASSOCIATION PLAN NO. <m: S Massachusetts -Department of Public Safety Board of Building Regulations and Standards ' C'unsh'urtiun Super�'isur License: CS-058633 MICHAEL J MCCAR PO BOX 52 W DENNIS MA 02671�� '1 b„ �� 1 1 11 111 1•1 Expiration Commissioner 04/10/2016 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 169393 Type: Individual Expiration: 6/16/2015 Tr# 238121 MICHAEL MCCARTHY MICHAEL MCCARTHY ------- - — ----- - ---�- P.O. BOX 52 --------— ---— — -- WEST DENNIS MA 02670 _______._.._.._..____._._ Update Address and returb•card.Mark reason for change. (� Address ❑ Renewal r ]'Employment ❑ Lost Card SCA 1 Co 20M-05/11 ../ __. �... .. _._._ _................. �_...,,.. __..,.._.._.....-.._......_....-,_......_... _� _.. .-...__..m__._..._....._..... The Commonwealth of Massachusetts Department oflndusirudAccidents Office of Investigations 600 Washington Street Boston;M4 02111 imminass govIdia Workers' Compensation Insurance Affidavit: Builders/Contractors/Elecfricians/Plumbers Applicant Information Please Print Legibly ike McCarthy Construction Name(Business/Organizagon/lndividuai):_ )P® Box 52 Address: West Dennis, MA 02670 City/statelZip: CSI §§#3 HIC-169393 Are y u an employer?Check the appropriate box: Type of protect(required); 1. I am a employer with 1 4. ElI am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole propridtor or partner- listed on the attached sheet t 7. []Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for mein any capacity, workers'comp,insurance. 9. ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions. myself. o workers'comp. e.i52, 14,and we have no Y � p � ( }�ra 12.[]R f repairs insurance required.]t employees.[No wothm' 13. er comp.insurance required.] ;Any applicant that cho4m box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating thoy are doing all work:and then hire outside contractors must submit a new affidavit indicating such. tContmetors that check this box must attached an additional shca showing the name of the subcontractors and their workers'comp.policy In mmatiom lam an employer that isproviding workers'compensation hisurance for my employees Below Is thepolicy andjob site Information. Insurance Company Name: Policy#or Self-ins.Lie.#: V WC. 'c e9-(�o►'IC,4. " -10'4.1A Expiration Date: Job Site Address: y l ar.�'� - C��c l c City/State/Zip; Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). F Failure to secure coverage as required under Section 25A ofMGL c.152 can lead to the imposition ofcriminal 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 DU for insurance coverage verification. I do hereby certo tt dLhe pa a enalties afperjury that the Information provided ov is true and correct. s � Signs D te: Z� N Phone#: - r i 0fj7ctal use only. Do not write in this area,to be completed by city or town official } City or Town: Permit/Lleense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3,CitylYown Clerk 4.Electrical Inspector 5.Plumbing Inspector _ 6.Other - Contact Person: Phone#: 2AC D® CERTIFICATE OF LIABILITY INSURANCE DATE 07/1a/DD/YYYY) o7zola 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). pN�p PRODUCER 01962-001 NAME:CT Bryden&Sullivan Ins Agcy of Dennis Inc A/C.No.Et): (508)398-6060 •No.: (508)394-2267 PO Box 1497 �Sss: So Dennis,MA 02660 k INS RERIS)AFFORDING COVERAGE NAIC# INSURER A: A.I.M.Mutual Insurance Company. 26158 INSURED INSURER B: Michael McCarthy Construction Inc -- INURR . P O Box 52 INSURER D: West Dennis,MA 02670 - - ` INSURER E:INSURER E -- .. `..w. 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. NO T IVVITHSTANDING ANY REOUIRENIENT, TERM OR CONDITION OF ANY CCIITRACT OR OTHER DOCUMENT WITH RESPECT TO 'AI-IICH 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. ILTR TYPE OF INSURANCE I SR � POLICY NUMBER MM E MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE, $ COMMERCIAL GENERAL LIABILITY r. DAMAGE TO RENTED $ PREMIS I E Ea occurrence �, CLAIMS-MADE "❑OCCUR t MED EXP(Any one person) $E — PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: I t a PRODUCTS-COMP/OP AGG $ - OLICY F UECT RO- `OC AUTOMOBILE LIABILITY _ ( Ea accI idea SINGLE L MIT $ I �IANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ _ AUTOS AUTOS _ ~— NON-OWNED PROPERTY DAMAGE HIREDAUTOS AUTOS ( ide $ HUMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADE AGGREGATE $ DED I I RETENTION $ $ • �i����I��Lo�Ns� Awl"r X T - 14S °� A gpRMQ�RIPARTNER/E)(ECUTIVE YIN E.L.EACH ACCIDENT $ 500,000.00 A o lc REtXnC��LUUDDEED7 v1 NIA VWC-100-6017656-2014A 7/17/2014 7/17/2016 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE$ 500,000.00 UMINPM OF 6PERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000.00 DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space Is required) Workers Compensation Coverage applies to MA employees only. CERTIFICATE HOLDER CANCELLATION Thieisch Engineering 195 Francis Avenue, SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cranston,RI 02910 THE, EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE - ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010106) The ACORD name and logo are registered marks of ACORD S6$-1yC- U1�y OWNER AUTHORIZATION FORM '(Owner's Nam' -),- owner of the property located at G, C .(Property A dress) (Property•A dress) herebyauthorize- `� S ' (Subcontractor) an authorized subcontractor for RISE Engineering, to act on my behalf to obtain a building permit and to perform work on my property. s Owner's Signature R / Date(, 1 , j IT PR MAR `: ® 2014 D (0 i 'THE r �, g Town of Barnstable *Permit# b �F$�V��fA�l.� Expir�manthsrom date Re ulato Services Fee.:P `� g rY * sAivasrAsr E + MASS' Richard V.Scali,Interim Director q 16;q. �9 tED MA't& , Building.Division Tom Perry,CBO,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address_ 6" Residential Value-of W_ork$- d����,` Minimum fee of$35.00 for work under$6000.00 F Owner's Name&Address ;0% &. y, C"47'e 5 p Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Email: ' Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: _ ❑ I am a sole proprietor FH I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# , Copy of Insurance Compliance Certificate must accompany each permit... Permit Request(check box)' ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to., Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) 0 Re-side Replacement Windows/doors/sliders.U-Value � S (maximum.35)#of windows B� g #of doors: Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections}required: Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: = .Property Owner must sign Property Owner Letter of Permission. ' A copy of the Home Improvement Contractors License&Construction Supervisors License is required: SIGNATURE: . Q:IWPFILES\FORMSIbuilding Pe t forms\EXPRESS.doc 4 e CamwomsieaUh ofWassuchUNMI r Depar tin,�'�'�s m&rr�lAecrdents ta - u e of Amleshkaiitrw 600 fYigslrarrgton Mreet Bosfor,AM 02111E wnw.ma=gm-ld rt Workers' Compensati€on-Insm-ance Affidavit:BdddersfC�antractorsMectriciansfMumhers APPdicant Inform.afien Please Pant Leaibly LName(f3� ni: onFlndividnai�: !� l 1/Q CiiyfStatt-1 : Phone Are you an employer?Checkffie appropriatebox:. Type of project ,r ' 4_ I arrr a. contractor and I I� �• I (required): ���- I.❑ I am a employer with ❑ 2� 6_ ❑New won employees(full and/or part-time).* have hired the sub actor% 2:❑ I am a'sole proprietor orpartner- listed on the attached sheet +. ❑Remodeling ship and have no employees These sub-contractors have. S- ❑Demolition wad ng for in any capacity_ employees and have workers' 9_ ❑Building addition [No workmss'comp.insurance comp-ttssuMMI 5. ❑ VJe area corporationand its 10_.❑Electrical repairs or additions t3 I am a homeowner doing all woriz officers have exercised(heir 1 j_.❑TIumbiug mpairs or additions Ef myself[No workers'comp- right of esmmption per MGL 12❑Rnof repairs nnuancerequired.]1 c-.15,,§1(4} and welineno employees ur_[No olke s' 13_❑Other camp-insurance required>I *Aap aaprDamr fiat cbecks boa-#1 roost also fDl out the section below sbnwing ibex vroalus'compensation policy ivflzmzfimL t Homeowners who submit this affidavit intlicitmg they are damg oRNro c and tbea hire outride court-a mrs mast sab a near affidavit it icnting.sarTL tContracmrs thst check this boos nK=attached an additional sheet shown g the name of die sub-ca aft3cb s and state whether armnt tbasa.MMesh=el emrhryees If the sub-contmaumbneemp7qyees,they mustprovide%drworkas'comp.policy number. lam an Salary is die po&cy and job site in fonnadom Insurance CompauyN=e: PaliU 9 or.Self-iris_Uc-& Fxpi ationDate_ Job Site Address ciiy#State/Tp: Affach a copy of the workers'compensation policy dedaration page(showing the policy number and expiration date). Failure to secure coverage as requireduuder Section25A of MGL c. 152 can lead to the imposition ofciiminal pmalties of a fine up to$1,500.Oa andlar me-year imprisonment,as well as civil penalties in.the fb=a of a STOP WORK ORDERand a fine of up.to $250-00 a day against the violator. Be advised that a cry of this statement maybe forwarded too the Office of Investigations of ibe DIA for insurance,coverage verifrc ation- I do h are by certify ruiner the UM'trs arrd pen aRies a,f'petfuwy dtatdie info rmaitian provided above is true trod correct sit I5at: / Zd •�Pht}r1$�: � f © k aI use aril,. Do not write in this area,to be cam by city or town vfsiaL City or Town: Pe rr ftUcense,# � .. , err r.l. ,. .. -.r. r r,•..m-- _... Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant-to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer;or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the - dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building'appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any, applicant who has not produced acceptable evidence of compliance with the insurance.coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." 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 cerificaie(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 retained 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"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call The Department's address,telephone and fax number: The Commanwe th of Massachusetts Department of Iudustdlal Accidents Q- ce of lawstintio-as 600 WashzVoa Street Ba toll,MA Q-111 Tel.A 61 -727-49W at 406 or .14 MASS THE Town of Barnstable Regulatory Services i F Thomas F.Geiler,Director ;A�►.`0 Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.b arnstable.ma.us Office: 508-862-4038 , Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: / ,=joB LocAnorr: o�� sf li/CMG number // street �J 9 village17 s 9 "HOMEOWNER": /� G!� z%I�ilQD��O✓DtS` - � G�� ��6 c �i�/ r- name home phone# work phone# CURRENT.MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION 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 minimum inspection procedures and re uirements and that he/she will comply with said procedures and requirements. Si a of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or Iarger 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. C:\Users\decolliIV,ppData\Local\Merosoft\VTmdowslTemporary Internet FileslContentOudook\QRE6ZUBN\EJ PRESS.doc oFmE T Town of Barnstable Regulatory Services ssniuvrE$* Thomas F. Geiler,Director fn M;c Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstafile.ma.us Office: 508-862-4038 'Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize to act on my bebalf, in all matters relative to work authorized by this building permit (Address of Job) **Pool fences and alarms are the ibili ons resP tY 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 Owner Signature of Applicant Print Name Print Name Date Town o c t _OS f Barnstable *Permit# 6 F.zpire:s mon tune issue Regulatory Services 1pb 16Fee j� �e Thomas F. Geiler,Director 1 Building Division Tom Perry, CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma us Office: 508-862-403 8 EXPRESS PIE ff APPLICATION - RESIDENTIA Fax: 508-790-6230 L.ONLY Not Valid without Red X-Press Imprint Map/parcel Number Property Address L��/ram ;�✓ . �IL��r- �(/nsAAO c. G l o Residential Value of Work- Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address Contractor's Name_ " Telephone Number 5i�O -7 7 `��670 G -10me Improvement Contractor License#(if applicable)1d Ve %onstruction Supervisor's License#(if applicable) ]Workman's Compensation Insurance d y I '-I Check one: til J ❑ I am a sole proprietor ❑ I am the Homeowner ❑rl have Worker's Compensation Insurance 1 0WlIN OF SARNSTA6L.E surance Company Name i orkman's Comp. Policy# J Ae )py of Insurance Compliance Certificate must accompany each permit. rmit Request(check box) �. { Re-roof(stripping old shingles) All construction debris will be taken to r J Re-roof(not stripping. Going over existing layers of toofl ❑ Re-side #of doors ❑ Repladement Windows/doors/sliders. U-Value (maximum .44)#of windows *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy me Improv t Contractors License&Construction Supervisors License is red. vATURE: ern crn........-.. .... The Commonwealth of Massachusetts Department of Industrial Accidents f Office of Investigations �'� tS00 Washington Street ?I s:?; i \'= / Boston,MA 02111 3- www.rnass..gvv/r�iri. Workers-"Compensation Insurance Affidavit; Builders/Contractors/Electricians/ Iumbers Applicant Information Please Print LeLdbly Name (Business/organization/Individual): Address: PO cax � -- City/State/Zip: UAla li Phone #: 7 Are you an employer?Check the appropriate box: Type of project(required): I. 1 am a employer with 4. ❑ I am a genend]contractor and I 6. ❑New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner listed on the attached sheet t 7•. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑.Demolition working for me in any capacity. workers' comp. insurance. g ❑Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its . required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1 I:❑ Plumbing repairs or additions myself.[No workers'comp. c. 152, §1(4), and we have no l Z oof repairs . insurance required]t employees.[No workers' comp. insurance required.] 13. Other Any applicant that checks box I must also frill out the section below showing their workers'compensation policy iafnrmatioir. 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 shoat showing the name of the sub-contracton and their workers'comp.policy information. I am an employer that is providing workers'co porsaiYon insurance for nsy employees. Below is the policy and jab site information. Insurance Company Name:--Old_95? .Policy#or Self-ins.Lic.#: Expiration Date.% J / Job Site Address: V� ' • City/State/Zip: ' Attach a copy of the Workers'compensation policy declaration page (showing the policy numbe nd 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/o'r one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to.S250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Invesiigations'of the DIA for insurance coverage verification. T do hereby c nder t( and penak7es of perjury that the information provided abo a is true and correct 'iiznafore: Date: f I7 'hone#: b' Official use only. Do not write in this area;to be completed by city or toxvn bfftciaL City or Town: Permit/License# ---------------------------- Issuing Authority(circle one): J 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 Iegal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal.entity, employing employees. However the owner of a dwelling house having not more than three-apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business onto construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter I527 §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 our situation an P Y d,if necessary,supply sub-contractors)name(s),address es and hone number(s)s along with e'address(es) p r( ) g their certificate(s)of insurance. Limited Liability Companies �LC or Limited Liability y 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 of idavit 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 Iaw 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 yod 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 pernit/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 an business permit not related to P y, m ss or commercial venture (Le. a dog license or permit to burn leaves etc)said person is NOT required to complete this affidavit The Office of Investigations would hle 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 T_1 11 Lyrf nnrf Annn _ 1 •ni . .,.,r, � . .... �.�.._ - _ of l Town of Barnstable Regulatory Services. Thomas F.Geller;Director �Fn 1wd Bulldzng DIYI3IOII Tom Perry,Building Commissioner 200 Main Street,Hyammis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owrier'Must Complete and Sign This Se edon If Using A Builder I, as Owner of the sub.'ect� J .pro Pay' hereby'authoaize .W=C(4A rz D Rvi fG--I.1 1<0 Pr to act on my behalf is all Matteis relative to wvrk-authorized by this buMng permit application for (Address of Job) r� sn,,,m of owner Date 2 �N print Name If kMnerty Owner is applying forpermitpleasecoco Iete. the Homeowners License Exemption Form on :the reverse side. ��Yxsr� Town of Barnstable ;. Reg-alatory Services U MrILB= � Thomas F. GeBer,Director '•% Building Division ti Tom Perry,Buildin Commis oner . . g _ 200 Maui.Streei;_HyannA 02601 R�.town.bztastabI us Offcc: 508-862-403 8 Fax. 508-790-6230 HOMEOWNER LICF1d5 EXEhiPT701d / Please Pri.t / I JOB TI LOCAON: A, j Cllee-!/ AA11�1& number street villa ..xOMEOWNER": 4 j[) 2n'-0 ljA SOP" z f f C> -�-- name h phone# work phone ' CURRENT MAILING ADDRESS: � ✓ :� ` f ^,101-1-1_ eity/town statt rip code The current exemptian for"homeowners"was exten d to include owner-occupied dwellings of six units or less and to allow homeowners to cagage an individual for who does not possess a license,provided that the owner acts as stmpctyisor. '. D ON OF EOf�EOW?MR Parson(s) who owns a parcel of land on which he! a resides br intends to reside, an which-fhere is, or is intended to- be, a one or two-firmly dwmMuL attached or de d structures accessory to such use and/or fazm sfructrars. A person who const-gcts more than one home is a o-ycar period shall not be considered a homeowner. Such "homeowner"shall snbMit to the Budding Offi ' on a foram acceptable to the Bumlding Official, that helshc shall be rcspoijsibIc for all such wort yerfmancd'under buUdiqg pennit (Section I og.1_1) The mmdcrsigncd"homeowner"asm—cs resp ility for compliance with the State Budding Code and other applicable codes, bylaws,rules and regulations. The.undcrsigned'homeownee c tifits that,hc! understands the Town of Barnstable BumldingDepartrpcnt minimum inspection proccdmmres and rcq iremen and that hdshe wmlt comply with said procedures and rcquitamcnts. Signature of Homccwna Approval of Bunlding•Ofacial , Note: Three-family dwellings contauin35,000 cubic feet or larger will be required to comply with the 3t ten Butlding,Code Sermon 127.Q Construction Caatrol. ' S01l�OWNER'S EXEh2F'IION • The Code states that: 'Ally bomcewncr perAmnmtg work for which a building parent is mquird shall be exempt from the provisions f this section(Scetici n l t9.1.1-Licasing of canstroetion Supervisors);provided tha t if the bmT= mcr engages a pasw(s)for hire to do such T that such Hamccwn a shall ad as supavisar." h�any homeowners who use this Gumption are unzware that they are assuming the rnsponsrbVities of a super visor(see Appendix Q, ties do Regulations for Inccosi+g CmLdmctian Supervisors,Section 2.1.5) This lack of awzrcness Men tauhs in serious prohlernz,partieutarty iat the homeowner hires unlicensed pc *+s- In this case,our Board cannot proceed against the unlicensed person as it would with i liceascd 3ervisar. The ha>noowocr acting as SupcYisar is ultiantely responsible. To cnnsure that the bomeowncr is fully await of hiAcricsaaesrbilidrs.manv earrarnenitire Massachusetts= DOartment of Public Safet Board of Buildimi Reaulations•and Siandards Construction Supervisor License License: CS 15041 Restricted to:.00 ' , RICHARD R FARRENKOPF 37 RIVERDLE SO S DENNIS, MA 0266U Mo Expiration: 11/22/2011 777_C:ommissi mer Tr#: 12277 - &IYJil7t09+,ClJEaL[{�.�� L Offce of Consu�ne�Att:strrs$Bas nes nl`�a �b h. € HOME IMP.. MEN.T CONTRACTOR i Registration t t 104835 Ty" ' t Expirtion !1"5&2012 I Indi�;d�l ' i rt a 's� FAR REM RQl`tRUOTION s :Farrenkop --h-tstc to ry I icense or registration valid for mdividul us&,6n y' , before.the expiration date. If found return to.,.-,- t 4: Office of Consumer Affairs and Business Reg�'i:lafi lb Park Plaza.-Suite 5170 Boston;MA 02116, E # a Not ,�and without signature }�/ N.jELERS J ER SQUARE WORKERS COMPENSATION CT 06183 AND EMPLOYERS LIABILITY POLICY r TYPE V INFORMATION PAGE WC 00 00 01 ( A) ¢ ' POLICY NUMBER: (XOUB-3207T53-9-11 ) RENEWAL OF (XHUB-3207T53-9-10) INSURER: THE CHARTER OAK FIRE INSURANCE COMPANY 1' NCCI CO CODE: 15318 INSURED: PRODUCER: RRF CONSTRUCTION PREFERRED INS AGENCY INC PO BOX 92 10 NEW ENGLAND BUS CTR DR HARWICH PORT MA 02646 STE 303 ANDOVER MA 01810 Insured is A PARTNERSHIP Other work places and identification numbersare shown in the schedule(s) attached. ' 2. The policy period is from d 06-0441 to 06-04-12 12:01 A.M. at the insured's mailing address. 3. A. WORKERS COMPENSATION INSURANCE: Part One of the policy applies to the Workers Compensation Law of the state(s) listed here: MA a= B. EMPLOYERS LIABILITY INSURANCE: Part Two of the policy applies to work in each state listed in item 3.A. The limits of our liability under Part Two are: e Bodily injury by Accident: 500000 Each Accident Bodily Injury by Disease: $ 500000 Pocy Limit Bodily Injury by Disease: $ 500000 Each Employee C. OTHER STATES INSURANCE: Part Three of the policy applies to the states, if any, Listed here: AL AR AZ CA. CO CT DC DE FL GA HI I��ID IL IN KS KY LA MD ME MI MN == MO MS MT NC NE NH NJ NM NV NY OK/OR PA RI SC SD TN TX UT VA VT° WI s WV D. This policy includes these endorsements and schedules: SEE LISTING OF ENDORSEMENTS - EXTENSION OF. INFO PAGE 4. The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All required information is subject to verification and change by audit to be made ANNUALLY. DATE OF ISSUE: 04-18-11 TP OFFICE: NAT'L PRGM'S-ORL 715 PRODUCER: PREFERRED INS AGENCY INC DIRECT BILL 014233 00715 Ad w TRAVELERS J WORKERS COMPEt\ ; ONE TOWER SQUARE AND '_;. HARTFORD, CT 06183 EMPLOYERS LIABILITY TYPE V INFORMATION PAGE WC 00 00 OVt- POLICY NUMBER: (XOUB-3207T53-9-11 ) CLASSIFICATION SCHEDULE: PREMIUM BASIS ESTIMATED RATES ESTIMATED TOTAL ANNUAL PER$100 OF ANNUAL CLASSIFICATIONS CODE NO REMUNERATION REMUNERATION PREMIUM SEE EXTENSION OF INFORMATION PAGE - SCHEDULE(S) SIC-CODE: 1751 ---------- * STANDARD TOTAL ESTIMATED ANNUAL STANDARD PREMIUM $ 5703 PREMIUM DISCOUNT, NONE 0900-20 EXPENSE CONSTANT 338 TERRORISM 30 TOTAL -ESTIMATED PREMIUM 6071 TAXES AND SURCHARGES 427 DEPOSIT AMOUNT DUE 6498 t _ Minimum Premium: $500 EMPLOYERS LIABILITY MINIMUM: $50 7 6 DATE OF ISSUE: 04-18-11 TP OFFICE: NAT'L PRGM'S-ORL 715 PRODUCER: PREFERRED INS AGENCY INC 00715 COUNTERSIGNED-AGENT s' z f LERS J WORKERS COMPENSATION- � /ER SQUARE i AND CT 06183 EMPLOYERS LIABILITY POLICY 3 EXTENSION OF INFO' PAGE-SCHEDULE -WC 00 00 01 "( A) k POLICY NUMBER: (XOUB-3207T53-9-11 )' INSURER: THE CHARTER-OAK FIRE INSURANCE COMPANY -15318-MA INSURED'S NAME : RRF CONSTRUCTION i y r RATE BUREAU'ID: 054709 + PREMIUM BASIS ESTIMATED RATES, ESTIMATED TOTAL ANNUAL : .PER $100 OF. ANNUAL- CLASSIFICATION CODE REMUNERATION REMUNERATION PREMIUM LOCATION 001 01 - FEIN 200391264 ENTITY CD 001 RRF CONSTRUCTION - 37 RIVERDALE STREET SOUTH DENNIS, MA 02660 LANDSCAPE GARDENING & D 0042 40000 4.03 1612 CARPENTRY-DETACHED*'ONE OR TWO {' FAMILY DWELLINGS 4 5645 60000 8.68, 5208 MA MANUAL PREMIUM $ 6820 •- -------------- .------- ------------ --------------------------- 1 .00% EMPL. LIAB. INCREASED LIMITS(9807) $ 68 DEVIATION PROGRAM CREDIT(9037) `10.00% .689 TOTAL PREMIUM SUBJECT TO EXPERIENCE MODIFICATION 619$ < EXPERIENCE MODIFICATION: . .92, MODIFIED PREMIUM .5703 TOTAL ESTIMATED ANNUAL STANDARD PREMIUM '5703 00% ARAP MODIFICATION'PROGRAM (0277) NONE' EXPENSE CONSTANT(0900) 338 TERRORISM (9740) 30 MA WC SPECIAL .,FUND AND TRUST FUND 42T TOTAL ESTIMATED PREMIUM 6498 DEPOSIT AMOUNT DUE 6498 . DATE OF ISSUE: 04-18-11 TP, SCHEDULE NO: 1 OF LAST 3. ; TOWN OF BARNSTABLE Permit No 20P62_-_ t YAU,r.>c Building.Inspector cash -____-- TTA � ,eeo. lie ''Fe YPY Y' OCCUPANCY PERMIT Bond "No building nor structure shall be .erected, and no land, building or structure shall be used for a new, different, changed, or enlarged use without a Building Permit therefor first having been obtained from the Building Inspector. No building shall be occupied until a certificate of occupancy has been issued by the Building Inspector." Issued to Cedar ?acres Real tv Trus' Address Lot 14A 54 CD^..1-Dass Circle, Hvannis Wiring Inspector (r i E �.f - �{. ,t, � Inspection date r t Plumbing Inspector �., Inspection date Gas Inspector ; �0/ Inspection date Engineering Department %�tf�LGf Inspection date 3 A 3 1 7 THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL SIGNED BY THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN REQUIREMENTS. I 19 �j f .. etBuilding Inspector __ I 1 1-tEREny.CERTIFY THAT THIS, FOUNDRT'Ot4 ' t$ LOC-rEp ON THE LOT AS S,kS�bYlu,A"� l �� CONFa;?„fig TO THE TOWN'�OF 4ki,6vS ,G ZoNftjG 'EGV"A9TtONS REGARDING-SETBACKS 'f 4bM STREET L;4s AN13 LCI7 LINES. 4 f • o a � o d -71 Mw eo-sr 1 . f N o � Vic, Assgssor's`"map and;lot number :....... SEI''iIC SYSTEM fVIL 'f E� L �` _• �� - � .' LED IN C��1?r�L�AI�fC Sewage Permit:number .:.......,;... / TA ' l�. . '• ....,.. .. `�- � ARTICLE "G1-.STATE • CODE'AND SANITARY: IVC. TOWN yo*TNEro� = ' TOWN ' OF BARN T`01U-E--­ . i 86BB$TAXIL MAO` B U I,L-D I R : I-IS P E C-TO R . op •6}9• `0� - - APP LIGATION FOR PERMIT TO. ......................... .......... . Build . TYPE OF.CONSTRUCTION „Wood Frame ,Dwelling,,,,,,,,,,,,,,,,,,, . .10:_19. .. ..19....7.8 _ ,. • . ..� to lam' TO. . O THE INSPECTOR OF BUILDINGS: The undersigned hereL y applies for a permit according to the- following information: Location .1. _ .....,Compass Circle,;,,Hyannis,,,,,i"Ma,,,,,,,,, ;, ... .... ......... Proposed Use. .....Dwelli.. .. .......................... . ...... ...... Zoning' 'District ......... ................... ........Fire District ........ .....: ......................................... ..... Name of.Owner . } ss ..... A!....... ......... Name of Builder h... Address .......?rP........ Name of Architect .... ........ ....... ..... .Address. ............... .......................... ...........Foundation .CQ�C Crete.. -...FU11..... Number of Rooms .......... ................... ....: �r:.. ... ................................... Exterior White ..c.q.da.K...Sk3a,I�.Q:] ...............Roofing .........:As}�ha1t..Shin:gles..........:............... Floors Carp.. ...... .......... . ............ .Interior Drywall.. ....... ............. ......:.......... . 1 • Nesting .... ........H. ..o.t:.....w a't.p.r,...Qa..I....................................Plumbing ......: .............................:. Fireplace ..............Azle.:....... ..................................................Approximate Cost.::$22;010.0-. .O.........:. ::.............,..:.....:.. Definitive Plan Approved.by. Planning. Board ____________�__------- __.19_______ Area ......... Diagram of ,Lot and Building with Dimensions' Fee ........ .............. 7�.�� SUBJECT TO-APPROVAL OF BOARD OF HEALTH ."o -- .I hereby agree to conform to all the Rules and. Regulations:of the Town of Barnstable regarding the above_ construction. ,_ -• Name ... sue... �L�r ....... Cedar Acres Realty Trust 20862 one stor ...:, Permit for .:.:... ........ ..�::.... - single famiT ................... - location .......6k Compass Circle................... i �...... ...Hyannis .................. Cedar Acres Realty' Trust i - Owner Type of Construction ............frame,,,,,,,,,,,,,,,,,, r-................................................................................. Blot ............................ Lot1!fA,........... eT Permif Granted November 27 ...19 78 . ti D"'ate.of Inspection .. .. ..19 ; Date Completed .. �,1 , :. . .19 PERMIT. REFUSED ............................................................. .. 19 ................ ...... ........................................ ............. .................................................. Approved .................................................. 19 Assessor's map and, lot number - ............................................ Sewage Permit number ... . � THE r TOWN OF BARNSTABLE Z HARISTLUL i "6 BUILDING INSPECTOR APPLICATION FOR PERMIT TO .............. 3uild................................................................................................. W F TYPE OF CONSTRUCTION ood rame Dwellina ..................................................................................................................................... .............1.n.-1.Q......................19.....r TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Location / x}...... Compass Circle, H annis. Ma. ................:............ ...........................................:.................................................................................................... Proposed Use Dwellinct ...............................................:............................................................................................................................. ZoningDistrict ........................................................................Fire District .............................................................................. Name of Owner .rD l,... 'A' , 0- !!,n,V L��+, Win..:Add Tess .....�:+.....�� � :�......................................... 01 Name of Builder ?.. .t! ...... ......... J..'....�Address ......�`� tI.;...r�.�; t..�r, ...................................... Name of Architect Address �^- -........................................................... Number of Rooms 1 ....t:....................................Foundation ....Con r7.ne e........?'".?:1 Exierior ...............�.7hite cedar Shinal S...............Roofng ..........A:.n, h: ................................................. ............................................. 7:+ s... Floors CametS R,^�,�.ra l l ....................................................................Interior ................,......,............................................................ I Heating ..................................................................................Plumbing .................................................................................. Fireplace .............one..........................:k................................Approximate Cost ..-22.:.�.n.n... n......................................... Definitive Plan Approved by Planning Board ________________________________19--------. Area ........1.n Q ................... Diagram of Lot and Building with Dimensions Fee '`' SUBJECT TO APPROVAL OF BOARD OF HEALTH i 1 '� J LI .yam G 2T I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. �- Name ..... /!...�?........ .. ................. r' - Cedar Acres Realty Trust A=310-,4'00 i l.\ , No .....20862 Permit for ......Q 9.A 91U.......... sinzle. family„dta cling....;,,,,,,,,,,,,,, LoccNion .......... ................ ` H annis `> .....................Y.................................................. Owner ......:..Cedar A`-res Realty Trust., Type of Construction ..........&AMQ..................... ' ................................................. ........................... Plot ............................ Lot .......�.J.4D.............. i Permit Granted ......*November 27 19 78 Date of Inspection 19 I i Date Comple(d ......................................19 , 1 �ERMIT REFUSED r ..................V 19 I . ...................... ...................... ................................. � Approved ................................................ 19 t ............................................................................... ............................................................................... r