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0028 CROCKER DRIVE
a r Townof Ba_r_nstable idi ng .. t Post This Cerd.So That rt.is Visible:From the Street-Approvedx,Plans Must be Retained o.n Job and this Card Must be'Kept NA$l SSA , ` Posted Until Final'Inspection:Has Been Made p � y t� Where a Certificateof Occupancy:is Required,such,Building shall Not be Occupied until,a-Final-Inspection has been made.s e ., _._,. ..... .� - _�. . _J Permit NO. B-19-1244 Applicant Name: COMMON AREA Approvals Date Issued: 04/17/2019 Current Use: Structure Permit Type: Building-Shed-Residential-200 sf and under Expiration Date: 10/17/2019 Foundation: Location: 28 COMMON AREA CROCKER DRIVE,HYANNIS Map/Lot: 306030-OOA Zoning District: Sheathing: Owner on Record: COMMON AREA Contractor Name.-_... Framing: 1 ' Contractor License: ' Address: i 2 Est. Project Cost: $0.00 Chimney: Description: 8'X 15' SHED �, Permit Fee:. $35.00 Insulation: Fee Paid`:- .$35.00 Project Review Req: 8'x15'shed located as shown on submitted plot plan. Final: Date: } 4/17/2019 I t � Plumbing/Gas ! Rough Plumbing: k..Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after�.issuance. All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structuresshall be in compliance with the local zoning by-laws and codes. This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the Final Gas: work until the completion of the same. �r Electrical The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Minimum of Five Call Inspections Required for All Construction Work: ` Service: 1.Foundation or Footing 2.Sheathing Inspection Rough: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final: 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund"(as set forth in MGL c.142A). Fire Department Building plans are to be available on site All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final Fr -•.ram- Town of Barnstable Building Department Services MA Brian Florence,CBO BAWMAS Building Commissioner MA I �1639. ��� 200 Main Street, Hyannis,MA 02601 Fp www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 PERMIT# , `'C FEE: $35.00 SHED REGISTRATION RESIDENTIAL ONLY 200 square feet or less c �nve- ,�� Location of shed(address) Vvillage A/afu F 411X T, '41,, 97.f1-,F3,5 14%e�as-y'ges- Property ner's name Telephone number b30/DD,� Size of Shed Map/Parcel# E-Mail In 6a liaI Signa re Date Hyannis Main Street Waterfront Historic District?. Old King's Highway Historic District Commission jurisdiction? You must file with Old King's Highway Conservation Commission(signature is required) Sign off hours for Conservation 8:00-9:30&3:30-4:30 PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE..PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. + e THIS FORM MUST BE ACCOMPANIED BY A J PLOT PLAN Q-forms-shedreg REV:08/6/17 • —_n/f Connelly I I �0 04 O n/f Pierce n/f Galipeou 11�?j, c g a. prop. 8' x 15' I _� " — shed ??7,3g. ' ``'^•,..•� HOUSE No. 28 • Exclusive Use existing three Ar8a building setback bedroom house _ lines tck existing house antee ex sting deck. 24?•38, an taus edge of travelled way st ckade n/f Macheras ence 13't 5?•91 CB/dh EASEMENT No. 2 fnd) ?14• 30 52'f� :H 4p•O0' n/f.Gallpeau 141* EASEMENT Book 5053 Page 9 CR0C KER al pr(va f e way 20,now R/VE CB/ n/f Vattle �@ Zoning District 1 •29' Front setback 20' to oce Side setback 10' cn Avenue Rear setback 10' The site is located within an Aquifer Protection overlay district. GENERAL NOTES The property lines and locations shown are taken from deeds and plans of record with field observations / checks by representitives of this office. See BCRD Plan Book 472 Plan 73 and Plan Book 567 Plan 87. For title see BCRD Book 21726 Page 238. Title: °F-*S BUILDING PERMIT PLAN - Christopher GJ, o C. • -, Site Location: Mossman (A28 Crocker Drive � ' °No.3592, Barnstable (Hyannis), MA -� clvl� � Prepared for: LNG James and Mary Alex Date: Trowbridge Engineering LL Sheet No. 6 February 2019 P.O. Box 733 Westminster .er. MA 014� 73� 1 °of 1 Cale: 1" = 400 (978) 874-5527 FAX 874-5265 °n o www.trowbridgeengineering.com M 08020—2 y TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Jf � y O Map Parcel Application r ' Z/ Health Division Date Issued"/,6 —le-( Conservation Division Application-Fee f Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address Village {J yr. %f Owner Siw. y �'�"y �� Address Telephone C, P T J r`� rf- Permit Requesto.�.; �-L A Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay 4 � Project Valuation ,- Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Ye2s O.,No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq, ) Or Number of Baths: Full: existing new Half: existing �' new- Number of Bedrooms: existing —new = r 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 V M /-�`Lx Telephone Number T131r 1:M o1S1_ Address License # 0-IJ 01N N 0171 Y Home Improvement Contractor# Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO kcn��« C SIGNATURE DATE i FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED a � MAP/PARCEL N0. ADDRESS VILLAGE r , - ...OWNER DATE OF INSPECTION: 4+ i, FOUNDATION FRAME 4 INSULATION FIREPLACE - ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL r GAS: ROUGH FINAL r' FINAL BUILDING ' DATE CLOSED OUT ASSOCIATION PLAN NO. j�, y Vepartmetit of industrial Accideizts Office of lavesUgations 600 Washington Street Boston,MA 02111 WW.mass gov/dies Workers' Compensation Insurance Affidavit: Builders/Contractors/Electridans/Plumbers-' Applicant Information Please Print Lekibl� 1V=e-(Business/organization/fndivi4*-.- •Address: City/St-at c 1.4 A / U 11 Y G Phone.#: l 7$ 3;f- Ci.q o`r• Are you an employer? Check the appropriate bog: Type of project'(required)•. 1.❑ I am a employer with 4.•Q I am a general contractor and,I have hired the sub-contractors 6• ❑New contraction .. employees(full and/or part-time).. - 2.❑ I am a"sole proprietor or partner- listed on 1he'attached sheet' 7. Q Remodeling ship and have no employees These sub-contractors have' '8.C,Demolition working for me M any capacity.' employees and have workers' 9. Buid " addition :[No workers' comp:insurance. comp.insurance.$' ❑ _ . required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions cers have exercised their I am a homeowner doing all work offi 11.[]Plumbing repairs or a dditions myself [No workers' comp. right of exemption per MGL. 12•E]Roof repairs . in.cm•ance required.]t c. 152, §1(4), and we have no employees.[No workers' 13.El Other bL°tL 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 subffit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such..f $Contractors that check this box must attached an additional sheet showing the name of the sub-contiactois and state whether or not those entities have. employees. If$ie 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 E information. Insurance Company Name: f Policy#or Self-ins:Li.c.# Expiration Date Job Site Address: City/State/Zip: Attach a copy'of the workers'compensation policy declaration page'(showing the policy number'and ezp ration date): Farlure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a - fine tip to$1,500.00 and/or one-year imprisonment, as-well as civil penalties in the form of a STOP WORg ORDER and a fine .' of up to$250.00 a day against the violator. Be.advised that a copy of this statement maybe forwarded to the Office of Inyestipations of the DIA for insurance coverage verification I do hereby certi d the pains-and penalties of perjury that the information provided above is a aKd correct Si afore: .�< �� • Date: Phone q Official use only. Do not write in this,area tb be completed by city or town official City or down: PermiVUceuse# 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#• Town of Barnstable V - "� Regulatory Services RARNSMAEM : Thomas F.Geiler,Director . 0.19. ��� Building Division ATFo nti►'�°' Tom Perry,Building Co mnnissioner 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: /Z7 I y JOB LOCATION: - g u,,, k, C �I.Cc.� 0,,r -L � y akinf number street �--�•— village- "HOMEOWNER': VaP xw name ? / n home phone# work phone# r CURRENT MAILING ADDRESS: 3J O f 7`fO 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 permit (Section 109.1.1) i 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 minim inspection procedures and requirements and that he/she will comply with said procedures and ti require ts. Signature f Homeowner Approval of Building Official s f. 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 actin g as Supe rvisor is ultimately g P responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the pemvt 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 ri several towns. You may care t amend and adopt such a fomi/certification for use in your community. Qfomis:homeexempt. gyt•�. . # N �.•r:` - THE Town of Barnstable OF 1p� Regulatory Services puxx `'$rE$ Thomas R.Geiler,Director. rEa � .Building.Division Tom Perry,Building Commissioner 200 Main Street,-Hyannis, yMA,_02601 www.town.barnstable.ma us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section -if Using A Builder �w I, , as Owner of the subject property hereby authorize to act on my behalf, in all matters relative to work authorized by this budding permit. (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. ` S ature of Owner S tune of Applicant '� � PP Print Name Print Name Date Q:FORM&OWNERPERMISSIONPOOLS 62012 • i n • n • c a n/f Connelly o a n 1z91' / E Y, U a n/f Pierce 03 n/f Gallpeau 117.23, c m bunding,aetbadc Tines dock extp�ens�ion ��k K 22��, HOUSE No. 28 Exclu Use } existing three Area bedroom house existing house st�nc e n ence y ing deck 'TC 24y and gtaha � �\ edge of travelled way n/f Maches "'Once a reIS l 5291 OU/dh EASEMENT No. 2 fnd) n/f Gdipeau 14•t EASEMENT Book 5053 ,- ` Page 9 . CR OCKE R to woY 20•Racy R/VE , ) n/f tattle ind 2.70. v EM Zoning District �e' Front setback 20' to Side setback 10' ocean Avenue '� r Rear setback 10' The site is located within on-Aquifer Protection overlay district. GENERAL NOTES " The property lines and locations shown are taken from deeds and plans of record with field observations / r checks by representitives of this office. 'See BCRD Plan Book 472 Plan 73 and Plan Book 567 Plan 87. For title see BCRD Book 21726 Page 238. Title: " -j"°F" _ BUILDING PERMIT PLAN Christopher�G � Site Location: Mossman N 28 Crocker Drive "° 921 IVIL�o �, Barnstable Hyannis), MA ' �ok,'pFGI `� Prepared for: TONAL �aG James and Mary Alex ate: Trowbridge Engineering, LLC Sheet No. _ 4 March 2014 9 9 ' 1 of 1 P.O. Box 733 Westminster. MA 01473 Scale: 1 = 40' (978) 874-5527 FAX 874-5265 an o. www.trowbridgeengineering.com M08020-1 ® J L LLmV $ a a ^ mxAa It a e A A a 3^ W xF $ �P W v 9 a fN � AA \ 4r) / FA o ID e � aaX� a x F a a � R R R 1} •v ®®® a N B lz 9t - N A R , u N R F A A � r ^ t2 A $ $ Cl) r a w A $ " ^ mAAa x F a yn u x F a Lo V A $A a a � � m � Cl) nN a N m o ® ® o a w in A - .. LO co e IL+ ► � F s � aR L N m R A F is nL`duiJ t,r a SCR In ri ri _ i'. I ► « a R fL) Y I z Q ; . m aa — O a C R A Wa _ le a a3( 0 u m w $ I - • Z ► " R - O C N • Y • m t2 a i@ - .. e r J ► n 9 C R rr�� � .. maa a ri N maaA cm ® V ` m • m A - Ch N f- N Nana ® u $ F P9 ic ! itis Ald 4- - m r 9 lQ • � N m 2 R A W a n $ A $ IQ r « m A R a ^ m � A l `C N F �Q m $ A yxH L 11 ac W ¢ LL FRS F m « = A $ Y O 3 ^ A $ „ V A $ ,Y w ^ $ r I" prO� go R W 2 teA A 1 LL ^ IQ _ N IQ / ix��r N SF • p \�, P T /6 N A n $ � � � � FRA s �� a �s•� . g • F $ A � 1—XIJ��� r an = $ L- L r �O a 3 « mA $ I r� C h iCM co Go ` q�yo� W N cc w10 N m F $ A a « = A R A IQ r w X A $ .. ... .. .. .. ..... ...... ...x ., ... 14 This home has added bedrooms, bathroom, living space and has up to 12 people staying at this location at a time. This cannot be goad for the Septic in the area and with showers, bathrooms etc must overflow the current septic system. Please check this, cannot be good for the groundwater, must not be safe to have so many people living 'in such a small space. in the event Y of ;-Ire flood, etc. AUG 3"0 RECD h~ 5 s Ziia •�1; ..,r i s.•. o vi" 3 `4'..,v t w�^a s 3 0 -.C.3 �tJ a1 Y.;]••`��.,f y.l•7. .� �,.t,d�. ro � �°.� .xS w.J k.Y ...� t �°..� f s%•.. i 4 a vY \I Home:Departments:Assessors Division:Property Assessment Search Results New Search Ly New Interactive Maps>> r �R -n k Owner: 2010 Assessed Values: ALEX,JAMES D&MARY F 28 CROCKER DRIVE 2010 Appraised Value 2010 Assessed Value Past Comparisons Map/Parcel/Parcel Extension Building Value: $321,200 $321,200. Year Total Assessed Value 306 /030/OOA Extra Features: $16,900 $16,900 2009-$370,100 Outbuildings: $0 $0 2008-$406,800 Mailing Address Land Value: $0 $0 2007-$406,800 ALEX,JAMES D&MARY F 2006-$380,100 2010 Totals $338,100 $338,100 335 STILL RIVER RD BOLTON,MA.01740 �1 2010 REAL ESTATE Tax Information: Tax Rates:(per$1,060 of-valuation) Community Preservation Act Tax $78.81 Fire District Rates Town Residential Barnstable FD-All Classes $2.43 $7.77 C.O.M.M.-All Classes $1.26 Town Commercial Hyannis FD Tax(Residential) $615.34 Cotuit FD-All Classes $1.56 $6.87 Hyannis-Residential $1.82 Town Tax(Residential) $2,627.04 Hyannis-Commercial $2.88 W Barnstable-AII.Classes $2.28 Community Preservation Act 3%of Town Tax Total: $3,321.19 Construction Details Building Property Sketch LegeXpet*y Sketch &ASBUILT Cards Building value $321,200 Interior Floors Pine/Soft Wood Style Condominium Interior Walls Drywall K iModel Res Condo Heat Fuel Electric .44 Grade Average Heat Type Elec Baseboard Stories 2 Stories AC Type None Exterior Walls Wood Shingle Bedrooms 3 Bedrooms rMi Roof Structure Gable/Hip Bathrooms 2 Full 22 14 Roof Cover Asph/F GIs/Cmp Living Area sq/ft 992 ' Replacement Cost $353,016 Year Built. 1987 (t{r' ° Depreciation 9 Total Rooms 5 Rooms i� f Land Gross Area sq/ft 2,336 CODE 1020 AsBuilt Card N/A Lot Size(Acres) 0 Appraised Value $0 View Interactive Maps Assessfd;Val6e $0 Sales History: Owner: Sale Date Book/Page: Sale Price: ALEX,JAMES D&MARY F Jan 25 2007 12:OOAM 21726/238 $375,000 CARTWRIGHT,SCOTT Apr 26 2002 12:OOAM 15093/074 $315,000 GALIPEAU,MONIQUE A Jun 15 1990 12:OOAM 7194/030 $1 Extra Building Features Code Description Units/SO ft Appraised Value Assessed Value FPL2 Fireplace 1 $3,700 $3,700 BLA Bsmt Liv-Aver 968 $13,200 $13,200 Property Sketch Legend BAS First Floor,Living Area FST Utility Area(Finished Interior) UAT Attic Area(Unfinished) BMT Basement Area(Unfinished) FTS Third Story Living Area(Finished) UHS Half Story(Unfinished) CAN Canopy FUS Second Story Living Area(Finished) UST Utility Area(Unfinished) FAT Attic Area(Finished) GAR Garage UTO Three Quarters Story(Unfinished) FCP Carport GRN Greenhouse UUA Unfinished Utility Attic FEP Enclosed Porch PTO Patio UUS Full Upper 2nd Story(Unfinished) FHS Half Story(Finished) SFB Semi Finished Living Area WDK Wood Deck FOP Open or Screened in Porch TOS Three Quarters Story(Finished) '� J I • lr /X }? 11.{1 t 11f.141{Ji.} _ LL r i It It TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map ZS(V Parcel 0 J(> &4 Application #c?> 6` J 7 3 Health Division Date Issued Conservation Division Application Fe Planning Dept. s, Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH_ _ Preservation / Hyannis Project Street Address Z�R 1rve4,,` Try Village Pi-Zs,A f)n e . M A Owner �-c,tip ROO1 Address Telephone "7-7 4 _ -5-7 3 — !fe to Permit Request Xbo Fig ,., � — �-x '0�, -� s C osccds. -4 ,� c ZU,h 2- 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. ❑ 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 (sg4t) Number of Baths: Full: existing new Half: existing F nevi a Number of Bedrooms: existing _new % v Total Room Count (not including baths): existing new First Floor Rom Count Heat Type and Fuel: ❑ Gas Ij Oil ❑ Electric ❑Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wool/coal stove: Liles ❑ 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) o� Name �,�rrCfilv-__c vJ 4 4144 Telephone Number s ' `IOC Address ! &rY?r_r! License # co 1. DI-n n i,: rn Home Improvement Contractor# Worker's Compensation # E a l 1_ Z 11 ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE ►�/ _ DATE � � � y , y FOR OFFICIAL USE ONLY z APPLICATION# DATE ISSUED— .-MAP/PARCEL NO._ "ADDRESS VILLAGE 4 ti is OWNER t i• DATE OF INSPECTION: K ' 'FOUNDATION f FRAME g INSULATION { FIREPLACE r ELECTRICAL: ROUGH FINAL s PLUMBING: ROUGH FINAL GAS:, ROUGH - FINAL :FINAL B.UILDING=... r:c. Il t DATE CLOSED OUT . 1 ASSOCIATION PLAN NO. 6 ' jL - ' The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations- 600.Washington Street Boston, MA 02111 UV www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/EIectricians/Plumbers Applicant Information Please Print Le bi Name(Business/Organizadon/lndividual): Te_J .� City/State/ZiP Phone.#: j 1Ae you an employer? Check the appropriate bog: Type of project(required): ] I am a employer with J< 4• ❑ I am a general contractor and I employees(full and/or part time).* have hired the sub-contractors 6 El New construction 2.[] I am a sole proprietor or'partfter listed on the'attached sheet T. ❑Remodeling shipand have no employees These sub-contractors have 8. '❑Demolition working for me in any capacity. employees and have workers' 9. Buildin addition [No workers'•comp. insurance comp. insurance.$ ❑ g required-] 5. ❑ We are a corporation and its '10.❑Electrical repairs or additions 3.❑ I am a homeowner do' all work officers have exercised their I L[]Plumbing repairs or additions Myself [No workers' comp. right of exemption per MGL 12.❑Roof repairs insurance required-] t c. 152, §1(4), and we have no employees. [No workers' 13.[g'6ther cbmp.insurance required.] 'Any applicant.that checks box#1 must also fin 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 anew 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 crployees. If the sub-contractors have employees,they must providt their workers'comp,policy number. lam an employer that is providing workers'compensation.insurance for my employees. Below is the policy and job site information. _ I Insurance Company Name: "� 1 r a:y�l l-e fs e Policy#or Self-ins. Lic. #: /t V ZI Expiration Date: 1 21 2, Jib Site Address: /6 L �rpAASN City/State/Zip; Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to'secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK DRDER and a fine. of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce under the pains sand penalties of perjury that tire.information provided above is true and correct- Si afore: Date: S.h�l �- Phone#: �D-Z 351 Of use only. Do not write in this area, to be completed by city or town official .City or Town: Permit/License# Issuing.Authorty(circle one): I.Board of Health '2.B wilding Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector. 6. Other Contact Person: Phone#: , Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire., express or implied, oral or written." An employer is defined as"an individual,partnership,association, corporation or other legal entity, or any two or more a joint enterprise,and including the legal representatives of a deceased employer,or the of the fore o' en ed m ] rp g g eP mP g �. �g. receiver or tinstee 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 appurtenant thereto shall not because of such employment be deemed to be an employer." the grounds or buildin a urt or on gr g PP ti 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() 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 01 out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-.contiactor(s)name(s),-address(es)and.phone number(s)along with their certificate(s)of insurance. Limited Liability Companies.(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license.is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain-a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self- suran=.license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete'and printed legibly. The Departinent has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contactyou regarding the applicant. Please be sure to fill in the permit(limnse number which will be used as a reference number. In addition,an applicant that must submit multiple permitdicense 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 cbpy of the affidavit that has been officially stamped or marked by the 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 cifizen is obtaining a license or permit not related fo any business or commercial venture (Le. a dog license or permit to bum leaves etc.)said person is NOT required to complete.this affidavit The Office of Investigations would bke 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: 4 The Commonwealth of MassaGhusetts j Dgpartmmt Gf Ir].dusttd.Ed Ac-GideIltS -' Office of Investigatto-as' 600 Washington Street RostGn,MA 02111 Tel. #617-727-4900 ext 406 or 1-977-MASSA_FE Fax# 617-727-774 Revised 11-22-06 www.mass.gQy/c.a 1 oFVEro,,ti Town of Barnstable . F Regulatory Services t MARS. Thomas F. Geiler,Director Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 f www.town.b arnstabI e.ma.us Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section. If Using A Builder i as Owner of the subject property hereby authorize �H / � ,� Pea to act on my behalf in all matters relative to work authorized by this building permit application for. (Address of Job) Signature of Owner. to Print Name If Propea Owner is applying for permit please complete the Homeowners License Exemption Form on the reverse side. Q:F0RMS:0Wi MRPERMISSION Town of Barnstable "o Regulatory Services sAxrrs2�sr E f Thomas F. Geiler,Director r� ,� Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma us Office: 508-862-4038 Fax: 508-790-6230 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 h 1 � 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. l ;' `DEFINMONlOFHOMEOWNER _) 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.f:1)"s 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 B arnstable Building Department minimum inspection procedures and requirements and that he./she will comply with said procedures{and requirements. Signature of Homeowner Approval of Building Official — r, 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 Supervisor;);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 Iicensed 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 heishe 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:\WPFILES\FORMS\homeexempt.DOC OP ID:AK CERTIFICATE OF LIABILITY INSURANCE °AT 03102112 03/02/12 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). CNTACT PRODUCER 800-824-5201 NAME: Berry Insurance Agency PHONE FAX 9 Main Street 508-520-6914 A/c No Ext: A/C No): Franklin,MA 02038 E-MAIL Daniel P.Sullivan ADDRESS: PRODUCER UNDER-1 CUSTOMER ID#• INSURER(S)AFFORDING COVERAGE NAIC# INSURED Undercover Tent&Party INSURERA:St Paul Fire&Marine Ins.CO. Tony Prizzi INSURER B:Quincy Mutual Fire Ins.Co. 15067 31 American Way South Dennis, MA 02660 wsuRERc:The Travelers Insurance Co. 19038 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE DDL UBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DD/YYYY MMIDDIYYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CK00222216 05/02/11 05/02/12� DAMAGE To RENTED 10O 000 .PREMISES Ea occurrence $ � CLAIMS-MADE OCCUR MED EXP(Any one person) $ .5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 1,000,000 POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) B ANY AUTO AFV205655 05/02/11 05/02/12 BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ X SCHEDULED AUTOS PROPERTY DAMAGE $ X HIRED AUTOS (Per accident) X NON-OWNEDAUTOS $ $ UMBRELLA LIAB EACH OCCURRENCE $ EXCESS LIAB H2OCCUR CLAIMS - - -MADE AGGREGATE' $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY T R LIMIT R C ANY PROPRIETOR/PARTNER/EXECUTIVEY/N XEUB1999T91211 11/21/1 11/21/12 ,L.EACHACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? ❑N N/A - - (Mandatory in NH) L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below L.DISEASE-POLICY LIMIT $ 1,000,000 A Equipment Floater CK00222216 0510211 05/02/12 (Limit 600,000 Deduct 1,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Party Goods Rentals CERTIFICATE HOLDER' CANCELLATION ELEANOR SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Elena Hood ACCORDANCE WITH THE POLICY PROVISIONS. 28 Crocker Drive Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD ORDER #: 9726-9 rr EVENT DAY: SATURDAY DATE: 06-02-2012 n r(OW fntl, Pa EVENT TIME: DELIVERY: FRI 06/01/12 PER CLIENT 31 American Way South Dennis, MA 02660 PICKUP: SUN 06/03/12 PER CLIENT Phone: (508)398-9000 Fax: (508)398-9091 SALES PERSON: TP PURCHASE ORDER#: Website: www.undercovertent.net ORDER DATE: 11-10 TERMS: C.O.D. BILL TO: SHIP TO: OPTION WITHOUT TREE ELENA HOOD - 28 CROCKER DRIVE 133 COX STREET HYANNIS MA HUDSON MA 01749 TEL: (774)573-0166 FAX: - QTY ITEM DESCRIPTIONS PRICE TOTAL 1 20X60 FRAME TENT(WHITE)-SET.STAKING CLOSE TO PAREMETER 775.00 775.00 1200 TENT LINER WHITE-PRICE PER SQ FT. 0.70 840.06 8 8X20 WINDOW SIDE WALL(OPTIONAL TO POINT OF DELIVERY) 34.00 r' 272.00 8 30" SQUARE CAFE HT. TABLE-INSIDE COCKTAIL PARTY - 9.50. 76.00 6 60"ROUND TABLE 8.50 51.00 4 6'BANQUET TABLE-BUFFET&BAR '.8.00 32.00 50 FRUITWOOD BALLROOM CHAIR--IVORY CUSHION. '3.90 195.00 9 WHITE CHIAVARI CAFE STOOLS-WHITE CUSHION- 17.50 157.50 12 4X4 OAK PARQUET DANCE FLOOR s. 14.00 168.00 75 '4X4 BILJAX TENT FLOORING-GREY DECK 23.00 1,725.00 1200 SQ FT CARPET/TURF----------------OPTIONAL 0.45. 540.00 S 1200 CEILING LIGHTING-MINI LIGHT STRANDS-PRICE PER. SQ/FT 0.40 480.00 180 STRING LIGHTING y, " " 1.10 198:00 1 TENT PERMITTING FEE 150.00 150.00 6 8X10 DRAPE-WHITE 10.00 60.00 SPECIAL INSTRUCTIONS: k 'TOTAL: 5,71950 ELENA HERE IS ANREVISED QUOTE.TO RESERVE OUR SERVICES PLEASE,SIGN AND RETURN WITH A$750.00 DEPOSIT. WE CAN MAKE SALES TAX:` 348.09 CHANGES TO`SUIT AS NEEDED.THANK YOU. DELIVERY: "45.00 w LABOR: . 0.00 " TOTAL:. .6112:59 DEPOSIT PAID: ._ 500.00' Customer Signature} Date BALANCE DUE:' 5612.59 *Customerr is responsible for'obtaining necessary permits and marking of any underground utilities. t F IMPORTANT DOCUMENT Certificate of Flame §sis-tance ISSUED BY Date-of Shipment 3/23107 Registration Number ACNOW0, nINDUSTRJES INC. Tent Identification F140.1 44 5385 EVANSVILLE, INDIANA. 47725 ' MANUFACTURERS OF THE FINISHED TENT PRODUCTS DESCRIBED HEREIN This is to certify that the materials described have been flame-retardant,treated (or are inherently noninflammable)-and were supplied to: 810280 UNDERCOVER TENT& PARTY INC = is 31 AM'ERICAN WAY SOUTH DENNIS, MA 02660 ' G ; C _ Certification ishereby made that: The articles described on this Certificate have been treated with a flarrle-retardant approved chemical and that the application of said chemical was done In conformance With California'Fire,, Marshall Code. All fabric has been tested and passes NFPA 701, CPAI 84, r Serial $151200C 0) Description of item certified: CENTURY END 60W X.20 HOLE SNYDER WHITE VINYL 1023970A Flame Retardant Process-Used Will Not Be; Removed $y Washing And Is effective Far The Life Of The Fabric SNYDER MFG NEW'PHILADELPHtk,OH Nanie of Applicator.of Flame Resistant Finish l _ Signed: � i AN HUSTRIES INC. M oF� r Town of Barnstable Permit# Expires 6 mon am iss. e Regulatory Services Fee i + + BARNSTABL$ MA & Thomas F.Geiler,Director 9 i639. �ATfC MA't A Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-79.0-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number �Q CY v U«% Property Address -P A= [Residential Value of Work - Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address ' 9dc Contractor's NameTelephone Number - Home Improvement Con( or License#(if applicable) Construction Supervisor's License#(if applicable) ,. , ❑Workman's Compensation Insurance rne: AsaOV 2 �`� 201-1 a sole proprietor _the Homeowner ' /!�(O BARNSTAE3L ❑ 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(stripping old shingles) All construction debris will be taken to ❑ Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side #of doors Replacement 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 of the Home Improvement Contractors License&Construction Supervisors License is required. SIGNATURE: Q:\WPFILES\FORMS\building permit forms\E SS.doc Revised 070110 f The Cealar mohstwakh of Massachuseta Department of Industrial Accid erits Office. of Invesfigadons s 600 WashhWton Street Boston,.MA 02111 rncmmus gov/dia Workers' Compensatium Insurance Affidavit: Builders/Contractors/Electiicians/Phunbers . Applicant Information Please Print Legibly Name dual): mess: a�U City/State/Zip: Phone# Are you an employer?Check the appropriate b Type of project(required)- 0 aired): . I arcs.a contractor and I 1.0 I am a euployer with 6_. 0 Nrrw caastruction loyees('/till and/or part-ti=).: have:hired the sub-contrac ms a sole proprietor ar partner listed anthe attached sleet. 7. o delis f am �� g ship.and have no employees These sub-contractors have g_ ❑Demolition working forme in any capacity. . employees and have workers' . [NO workers'comp.insurz cue comp-iusvranm: �. Building addition , required.] 5. ❑ We are a corporation.and its 10.E]Electrical repairs or additions 3.❑ I am a.homeowner doing all work officers have exercised their 11.Q Plumbing repairs or additions mYself ' right of exemption per hIGL _ �oworkers GQmP� . 12..D Roof repairs insurance rewired.]T'. c.152, §1(4),and we have no employees.[No workers' 13,El Other comp.insurance ngLfired.] *Any applicant that checks bra#1 must"fill am the section below showin heir workers'compensation policy Fnformatin Homeowners who sub mrt this af5drat indicating trey are doing all tra t iLnd then hire ouesi&contractors must submit'a new af6dwit indicating such_ k;ontmcturs that check this boat must sttached an addireanal sheer showing the name of the sub-ctnaractan and state whether or not Those entities hsee employees. if the sub-,contractorstave employees,they must.ptauide dbeir Workers'croup.policy number. I yam an employer that is providing workers'congwzsalion insurance for my emplojwA Below is thepo&.y and job site information, Insurance Company mate: Policy or Self-ins.Lie,* Expiration Bate: Job Site Address: CityfStatelZip: , Attach a copy of the workers'.compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under.Section.25A of MGL c- 152 can lead to the imposition of cr'+rr inalp aalties of a fine up to$1,50G.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 forwarcded to the;Office of Investigations of the DIA for mimm„r•e coverage verificatiozz I do hereby cerdA under the pains and penabYes of iuy t the info.rmaf&n provided ai ov is bue and correct 5i11f Date: Phone#: offl at n anlyy. Do not write fn fins area,io bit courpWod by cit3.or tetwi oficiai City or Town: PermitUcense# Issuing Authority(circle one): 1..Board of Healiir 2.Building Department 3.CitF/rown Cleric Electrical Inspector.S.Plumbing Inspector 6.Other Contact Person: Phone#: 6_ °Ftrti Town of Barnstable °^ Regulatory Services Thomas F. Geiler,Director Mass. 9`b°T16 .t Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis, MA 02601 www.town.barnsta ble.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: C number street village "HOMEOWNER": name ho a phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER i 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 Perforrried under the building permit. (Section 109.1.1) A } 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 h she w' 'corlltply with said procedures and requirements. SigffattrebMorfie6whe Approval of Building Official C Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127A 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, I .( 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 caret amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc Revised 070110 r LLgg OF SHE + + + &UMSTABM + ' ,�� Town of Barnstable i0rfv Mar" Regulatory Services Thomas F. Geiler,Director . Building Division Thomas Perry, CBO Building Commissioner. 200 Main.Street, Hyannis, MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 ` Fax: 508-790-6230 Property Owner Must k Complete and Sign This;Section v� If Using A Builder l ; as Owner of the subject property R hereby authorize ' — to act on my behalf,' in all matters relative to work authorized by this building permit application for: -.241 (Address of Job) f 1 i Signature of wner Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on.the reverse side. - QAWPHLESTORWbuilding permit forms\EXPRESS.doc Revised 070110 The Commonwealth of Massachusetts c I Department of Industrial Accidents VRk1l. I; Office of Investigations y� tit; 600 Washington Street r. Boston, MA 02111 tl'rtl R / c www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual): Address: City/State/Zip. l Phone#: "02) -7 7&-0t&, Are you an employer?Check the appropriate box: Type of project(required): 1.❑K11a a employer with 4. ElI am a general contractor and 1 6. ❑New construction floyees(full and/or part-time).* have hired the sub-contractors2 44 a sole proprietor or partner- listed on the attached sheet. $ 7• ❑ Remodeling . ship and have no employees These sub-contractors have 8. [],Demolition working for in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp, insurance . 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions- 3.❑ l am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself.-[No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' comp. insurance required.] 13.❑ Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a 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 D1A for insurance coveraX verification. . I 1 hereby certi n er th ai s nd p [i erjury that the information provided(abp ve is t ue and correct Si nature: 1 Date: ! `� Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the, owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,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 lop Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City 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 u Y o regarding the applicant. g Y g g PP Please be sure to fill in the pennit/license.number which will be used as a reference number. In addition an applicant that must submit multiple permit/license applications in an p p pp y given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all.locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations,would like to thank you in advance for our co g y y operation and should you have any questions, ass,. please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax # 617 727-7749 Revised 5-26-OS www.mass.gov/dia S61f 1pt, Town ®f Barnstable *Permit#`6:2()0 ©";?7 3�o E i Expires G montlu jrorn issue date DMINSTABtE. • Regulatory Services Fee 007 Thomas F.Geiler,Director �pfD�A, _ _ Building Division OWN F BAD"���A��� Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.bamstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ')NLY Not Valid without Red X-Press Imprint Map/parcel Number o Property Address 0. �� C-1' S NResidential Value of Work `-'iC)CO Minimum fee of$25.00 for work under i�Owner's Name&.Address m�sAlex 33 &Yerm Contractor's Name -Ze Aa L Telephone Number Home Improvement Contractor License#(if applicable)_ tOa> Construction Supervisor's License#(if applicable)_ PsWorkman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ lam the Homeowner I have Worker's Compensation Insurance Insurance Company Name OV C ' ('S 1J5 Workman's Comp.Policy Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to ` (' OA )—a VA ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) *Where required: Issuance of this permit does not exempt compliance with other town departinen r IiAdda Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. Home Improvement Contr tors License is required. t Wd £r SIGNATURE: 0 1 QCz V. Q:Forrns:expmtrg Revise071405 f N The Commonwealth of Massachusetts Department of Industrial Accidents V Office of Investigations 600 Washington Street Boston,MA 02111 �c www.mass.gov/dia ' Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Itidividual): ��— Address:AQ-6\ n L) City/State/Zip: "�-�� ���� w� r S_� Phone #: sot . q 21 — 1 Are you an empic cr?Check the appropriate box: Type of project(required): 1.2® I am a emplo,�r with 4. ❑ t am a.general contractor and 1. 6. ❑Nc,v construction employees( i and/or part-time).* have hired the stib-contractors 2.❑ I am a sole p..;prietor or partner-. listed on the attached sheet. 1 7 ❑ 1Zc,iIodcling. ship and hav no employees These sub-contractors have 8. ❑ Dc.nolition working for ;:;c in any capacity. workers' comp. insurance. q ❑ Building addition [No workers comp. insurance 5• El We arc a corporation and its required.] officers have exercised their 16.❑ Electrical repairs or additions 3.❑ I am a homcowtier doing all work, right ol"exemption per MGL I I.❑ Plumbing repairs or additions myself. [No workers' comp. C. 152;§1(4),and we have no 12�KR(1;)f repairs insurance required.]t, employees. [No workers' comp. insurance required.] 13.0 Ot;=_ 'Any applicant that checks hox#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a kw affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. I am an employer ilia.,is providing workers'compensation insurance for my employees. Below is the policy.and yob site information. Insurance Company Name: r 0A Q cs Kys Policy#or Self-ins Lic.#: \ , ---�I wcq b Co nU Expiration Date: [�� _.."l1 . � Job Site Address; ity/State/Zip. A 02 96 Attach a copy of the Workers' compensation policy declaration pale(showing the policy numl;cr and expiration date). Failure to secure coverage as required under Section 25A of MGL 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 forwa-ded to the Office of Investigations of the DIA for insurance.'coverage verification: I do hereby c under the pains'and enalties of perjury that tl:e urformation provided ab ve i.�true and correct. Si nature:` Date: Phone# . . . Official use only, Do'not write in this area,to be completed by city or town official City or Town:" Permit/License# r Issuing Authority(circle one): " I.Board of Health .2.Building Department 3.CiVFown Cleric 4,Electrical Inspector S. Plu 6.Other p mbi�tg Inspector Contact Person:_ Phone#: Town of Barnstable o e g .atoY- Se Rrvices $ ThOMas T.Geiler,Director EjUding Bivisiom Toml:'arny, Builcling Commissioner 200 lY3:xtin Street, Hyannis,MA 02601 .;'°*W.toWn.bamstable.ma.tis Office: 508-862-403 8 508-790-6230 Property 0' er Must _Gompkte and Sig - Th s Section. I.0 U sing .A,Build(-,r J h s1 Inc as F DRTiet of.the subject i" vf'tGTtY hereby aut1b oznze `CCN �ti;L J 00. ��►• to act a: I-u be Z ----�— Y. half in all math`:i;;:xelative to work aut.oxized by-this building permit application fc:: (A &css of job) /0,) Sipat4 of Owner Date, Phut Na.=e Board of Building Regulati ns and Standards One Ashburton Place - Room 1301 Boston, Massachusetts,02108 Home Improvement Contractor Registration Registration: 103714 Type: Private Corporation Expiration: 7/9/2008 PAUL J. CAZEAULT & SONS INC. Paul Cazeault --- 1031 MAIN ST OSTERVILLE, MA 02658 Update Address and return card. Mark reason for change. DPS-CA1 Co 5OM-05106-PC8490 r1 Address .� I Renewal I Employment Lost Card Ilo:u d of l3uildiug Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: .103714 Board of Building Regulations and Standards Expiration: '7/9/2008 One Ashburton Place Rm 1301 -Type:,Private.Corporation Boston,Ma.02108 PAUL J.CAZEAULT&SONS JNC Paul Cazeault 1031 MAIN ST OSTERVILLE, MA 02658`"'' Deputy Administrator Not valid without signature Board of Building egulations One Ashburton Place, Rm 1301 Boston, Ma,02108-1618 License: CONSTRUCTION SUPERVISOR LICENSE Birthdate: 10/20/1959 Number: CS 026325 Expires: 10/20/2007. Restricted To: 00 PAUL J CAZEAULT 1031 MAIN ST OS'T'ERVILLE, MA 02655 Tr.no: 7696.0 Keep top for receipt and change of address notification. PS-CA1 0 50M-04105-P.C86.98 i 5/7 C/>dI7N!'Lo97.(!/r.(7.G(/L oP✓'�.�rlQelt4 BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR 4 Number1 .CS 026325 B�rtdate:';10/20/:1959 Expires:'10/20%2007 Tr.no: 7696.0 Restricte"d 00 PAUL J CAZEAULT .,.. '.',..'. 1031 MAIN ST rr ®Cre ���t,r,.o, • �5. ,�.�J GATE(M410D1Y Y) °t z PRooucER THIS UTAT-EICATE'IS ISSUED •AS A fdATTER OG INi iFcr..aK►u. DOWLING & 0`NE.IL i';S AGC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE ' 222 wFs•C,hIA11; STRE.:T. HOLDER. THIS CERTIFICATE DOES NOT AMEND EXTEND''OR ALTER 9 0' ' '9 Th?E GOVERAGEAFFORDEQ flYTHE POL1ClE'�i flELIIVY_. HYANNIS VIA O .601 COMPANIES AFFORDING COVERAGE 99LGR` cGaJPAvr. A TRAY"I.-,'RS PROPERTY CA&UALTY GnMI'ANY C. AMER A COMPANY ' PAUL J; CAZGAULi & SONS .INC. B 1031 MASN STRE;1:.'; ;;O5,TFRVILLE MA. 2655' COMPANY C COMPANY — ..L st. ::Y<L`.' ---7777777777 THIS A-TO CERTIFY THA i 'ME POUCIES"OF INSU%'ANCE LISTED'BC HAVEB• k jjC a„a . r {"INDICATED;NOTW(THSTAI MING ANY REOUIREMPE T TERM OR COIN; : ION OF ANY CON';!,ACTOOR EOTHER DOCUMENT V41TH RESPECTAUOVE O(.I"i1CHERITHIS 4. CERTIFICATE MAY BE IS `TED OR MAY PERTAIN. THE INSURANCE A•♦ORDED BY THE Pt=hICIES DESCRIBED HEREIN IS SUBJECT TO ALL'1;iE TERMS, EXCLUSIONS AND CONDIT„jN3 OF SUCH POLICIES.'.IMITS-SHOWN MA`•'tiAVEBEEN REDUCL v BY PAID CLAIMS? ' CO { TYPE OF INSURAN..c, POLICY EFFECTIVE: POLICY EXPIRATION- f,�.�', LTR ..� � PO.:CY NUMBER �' � -DATL(rSADlAYY) QATE(MU\I1UWY). LIMITS ;:, `AENERAL'UA6IUTY '- t:UMMEH(,lALGtNrH,^_'ltA(NUIY GENCITALAGGII[GATC = `•. . NHLiulit i�Cudniaur irt)C. j 2 .•: '`'' CLAIMS MAOE L]OCCUR. PERSONAL X AOV.IN.111nY " L:ONIAA�!ORS PROT, s ;,.; ,• EACH OCCUnTiGNCC s ` FIRE.DAMAGE(My ono tiro) t _ AUTOMOBILE LIABILITYMED..EXPENSE.(Any ono peraon) S,ANY AU?Q COMBINED SINGLE LIMIT s ALL OWNED AUTOS SCHEDULED AUTOS RQPILY INJURY ^ ° (Per Person) S IiIRLO AUTOS t NON-OWNED AUTOS BODILY INJURY •s r`n t (PerACCidem) PROPERTYDAMAGE _ ' GARAGE LIABILITY AUTO'ONLY:EA ACCIOEN7' 3 f + r ANY AUTO+ _ r OT)iFR TMN AUTO ONLY. LACH ACCIDLNi, ; ! EXCESS LIABILITY AGGREGATL 3 UMBRELLA FORM FJICH OCCUnnf:NCG f AGGREGATE i OTHER THANUMBHEI'AFORM WORKER'S COMPENSATIG,N ANO. ` A '�raPLavEc�sLUDturY (UB-009..364—A-06) 08-10-06 08-10-07 STATUTORY LIMITS it F THE PROPRIETOR! EACH ACCIDENT f' df,+rPARTNERSlEXECUTIVE v INCL DISEASE—POLICY LIMIT e: OFFICERS ARE: EXCL >; „ DISEASE—EACH EMPLOYEE g JX tHI REPLACE:, ANY PRIOR CERTIFICATE L=1SI) I' THE CERTIFICATE HOLDER AFFECTING WORKER;, COMP C:'VE .•r. �.. F!� :, QL f.I.'t�::?r'���;vw :�1.::.s:<?j:xh:;•;4w:s' :�:,:.>.;1:-:: RAGE. ....n•...o.ya,:,•'i,.:... :"2�: �a.arc,'1.1VK' f,.::fi•,.: SHOULD ANY OF THE ABOVE OESCWBEO POLICIES BE CANCELLt,U, BEFORE THE , ` Paul J,Ci;"-.eault&Sons EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL[N:i@AyOR TO MAIL ` DT.`;S WRITTEN NOTICE TO THE CERTIFICATE HOLOE:*NAMED TO THE Roofing,e;.;,, LEFT, BUT FAILURE TO MAIL SUCH NOTICE SMALL IMPOSE NO <',BUGATION OR r, .1031 Mai`.Street LIAWUTY;;FAUY,KiNO.U"741IECOMpiia.'{,ITS.A„i►1TS.ai1REDFES;;3.;/.TiYirS... . L Ostervill MA 02655 ' AUTHOR)<::_U REPRESENTATIVE �J ���aCOR�S'�d 3�.�.t4y9�yy i tto �;•}.�i? •,:••;B:Ti:-i;y:�::8;L':'f,::;;•:t e> ..f. , l/✓^"•, • _ •' � � �Ftll:CtlHP 1993 r� 4 n rii11 c t Client#:19989 2CAZEAU LTPA ACOR®TM CERTIFICATE OF LIABILITY INSURANCE DATE (M IDDNYYY) PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Dowling Sr O'Neil Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Agency HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 222 West Main St PO Box 1990 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Hyannis,MA 02601 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA: Western World Paul J.Cazeault&Sons Roofing,Inc. INsuRERe: 1031 Main Street ` Osterville,MA 02655 INSURER C: INSURER D: INSURER E: - COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. TRW MD1 LTR INSRE TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY-EXPIRATIONDATE MMIDDIYY DATE MMIDDNY - LIMITS A GENERAL LIABILITY NPP1012091 04130/06 0413010.7 EACH OCCURRENCE $ 1 000 000 X COMMERCIAL GENERAL LIABILITY PDAMAGREMISES RENTED $50 000 CLAIMS MADE 51 OCCUR MED EXP(Any one person) $2 500 X BI/PD Ded:1,000 PERSONAL&ADV INJURY $1 000 000 GENERAL AGGREGATE s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $1 000 000 POLICY JET LOG - AUTOMOBILE IJABILITY COMBINED SINGLE LIMIT $ - ANY AUTO - (Ea accident) ALL OWNED AUTOS - BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS - BODILY INJURY - $ NON-OWNED AUTOS - (Per accident) PROPERTY DAMAGE $ (Per accident) . GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO - - OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE DEDUCTIBLE - $ RETENTION $ $ WORKERS COMPENSATION AND WC STATU- OTH- EMPLOYERS'LIABILITY TORY LIMITS I ER ANY PROPRIETORIPARTNERIEXECUTIVE - E.L.EACH ACCIDENT is OFFICER/MEMBER EXCLUDED? It yes,describe under E.L.DISEASE-EA EMPLOYEE $ SPECIAL PROVISIONS below - E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Certificate of insurance will be issued directly by the insurance carrier. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION Informational purposes only DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL IQ_ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SP SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AU�THOryRRPRESENTATIVE ACORD 25(2001108)1 Of 2 #42866 LS1 0 ACORD CORPORATION 1988 Town of Barnstable *Permit# �� xR Expires m no issue sued o® e\ /_ IT Regulatory Services Fee No 2 _ 2005 Thomas F.Geiler,Director Building Division 2-8� TOWN OF BARNSTA Tom Perry,CBO, Building Commissioner BLS 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY r �-J Not.Valid without Red X-Press Imprint Map/parcel Number 30 Prozesid Address Qa ential Value of Work k ���� Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address f PahVC-d— mtj g o 7 3 /Z-c Fh ,4 Contractor's Name SP G (,)u d M_g Telephone Number S �� Home Improvement Contractor License#(if applicable) 1 Lf O 5 7 Construction Supervisor's License#(if applicable) ❑Work:CFhk ' ompensation Insurance one:am a sole proprietor (� I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name.- Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) Bros G ® ❑ Re-side replacement Windows. U-Value (maximum.44) *Where required: Issuance of this permit does not exAnpt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: roperty Owner ust Property Owner Letter of Permission. ome Improve nt o actors License is required. SIGNATURE: G7j Q:Fonns:expmtrg Revise071405 6 .. f i 1 ✓/ze {iomr�maozcaea o� aaoac�ivae%ld Board of Building Regulations and Standards License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Board of Building Regulations and Standards Registration: 140571 '. ; One Ashburton Place Rm 1301 ' xp�ratroh_ 0/all ,�7/2007u,p 6 } Boston,Ma.02108 SPC BUILDERS S .fir . M SCOTT MENA �' T'f i 173 SEA ST ----------- HYANNIS,.MA 02601 Administrator N*vaidithout signature 4 Town of Barnstable Regulatory Services $ Thomas T.Geller,Director 05 Building Division Tout perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.ns Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A► Builder 1, 1 ajr r i ,as Owner of the subject property hereby authorize Cn 1" (2AA _1C to act on zany behaK in all matters relative to work authorized by this builditig perta:-�t application for: -(Address of Job) Signature of Owner ate Print Name Q F0XMS;0V4,BRPERMIMM1oN TO WC] Z2: 90 90OZ-9Z-130 �Ot1HE r, Town of Barnstable , *Permit# ' P Expires 6 months rom issue da e Regulatory Services ®P dD BAMSPABLE, . R gulato y Thomas F.Geiler,Director Building Division O F C j Tom Perry, Building Commissioner Toj/V,V O 2002 200 Main Street, Hyannis,MA 02601 p8m Office: 508-862-4038 - �ST��C� Fax: 508-790-6230 Q EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY �G` Not Valid without Red X-Press Imprint Map/parcel Number ` p/n� - Property Address ��'L � P Residential Value of Work Owner's Name&Address A,-e7 Contractor's Name/7�' D % �� ��/ Telephone Numbero Home Improvement Contractor License#(if applicable) 1. Construction Supervisor's License#(if applicable) _ "Ors Compensation Insurance Check one: t ❑ I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensatio Insurance Insurance Company Name i Workman's Comp.Policy# Permit Request(check box) . ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side Replacement Windows. U-Value s (maximum.44) ❑ Other(specify) 'Where required:.Issuance of this pe does not exempt compliance with other town department regulations,i.e.Historic,Conservation,-etc. Signature / Q:Forms:expmtrg Revised121901 j