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HomeMy WebLinkAbout0107 DOLPHIN LANE ell 10- - - - ------------ rod �J�k `ivT�zi� 4Euo-VA-f er"o. i i I i I i Application number VwFee .... ..................:............................... Building Inspectors Initials-&-pt................ LEDate Issued..... Q.....�.............. .........:.. Map/Parcel............::................................................... TOWN OF BARNSTABLE EXPEDITED'PERMIT APPLICATION: ROOF/SIDING/WINDO WS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: 10 k!tLtE, Rwa&4-v 1 O /f� STREET VILLAGE < Owner's Name:' �b1/lil� / ` 0H/ Phone Number ' Email Address: ` Cell Phone Number Project cost$ 0-0 0. Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize 00 to make application for a building permit in accordance with 780 CMR •. Owner Signature: Gy Date: cif' lizlt }, TYPE OF WORK © Siding 0 Windows (no header change)# Q Insulation/Weatherization. oors (no header change)# Commercial Doors require an inspector's review Roof(not applying more than 1 layer of shingles) . .. Construction Debris will be going to 4 CONTRACTOR'S INFORMATION � Contractor's name (I e PV-e— Z�7- 9 - knlle ' Home Improvement Contractors Registration(if applicable)# 0 ��. (attach copy) r Construction Supervisor's License# AMC ?0 (attach copy) j • U �1�! V• �: x Email of Contractor 2COcY�d2. - /-'—� f;O Phone number ALL PROPERTIES THAT WAVE STRUCTURES O R 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN '� A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAMBE ISSUED.' APPLICATION NUMBER.........................................................„.. *For Tents Only* Date Tent(s) will be erected Removed on number of tents total Does the tent have sides? Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one: this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with"the location(s)of each tent Fuel source being used LP tank 20 lbs. or> Yes No____,if yes, a gas permit is required. Natural Gas Yes No , if yes, a gas permit is required. If food is being served at.your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-4:30pm. Commercial events may require Fire Department approval, *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab right Offsets from combustibles: front back left side side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CAM the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the'Town of Barnstable. Signature Date APPLICANT'S SIGNATURE Signature K/ Date All permit applications are subject t a building official's approval prior to issuance. I � � ,} �� _ � � � { � .� �_� t 4 ...- .__ -- - - E ., � f _ I i f iCii- r - t Office of Consumer Affairs and Business Regulation t One Ashburton Place - Suite 1301 Boston, Massachusetts 02108 Home Improvemerito�rtractor Registration to ; ' Type: Corporation . � Registration: '168043 CAPE COD HOME `a�� �`'4 f - �-��� '" Expiration: 12l06/2018 27 MILL POND RD d ; '� � �� WEST YARMOLITH..MA 02673 �!� =.� Y " Update Address and Return Card. 0 20nr-osri7 n Office of Consumer Affairs&Business Regulation KOPAE IMPIROVEMENrrONTRACTOR Registration valid for Individual use only TYPE:(;Q'm cation before the expiration date. If found return to: Be istratI6.':t; Expiration Office of Consumer Affairs and Business Regulation 1E68043-: 12/06/2018 10 Park Plaza-Sui S�TO—� ti;,•-%rE COD I I::1h1F_IMPROVEMENT;INC. Boston,MA ., 4 A r t1A1 QLI 80W SKI Undersecretary Not valid without signature' F ACQRa CERTIFICATE OF LIABILITY INSURANCE FDATE(MMIDDIYYYY) �� 06/15/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Linda Sullivan _ DOWLING & O'NEIL INSURANCE AGENCY A"g"o E,�. 508)775-1620 FAx A/C,No): _ ADDRESS: lsullivan@doins.com 973IYANNOUGH RD INSURER(S)AFFORDING COVERAGE NAIC9 HYANNIS MA 02601 _ INSURER A: AMGUARD INSURANCE CO_ 42390 INSURED INSURER B: CAPE COD HOME IMPROVEMENT INC INSURERC: INSURER D: 27 MILL POND ROAD INSURER E: WEST YARMOUTH MA 02673 INSURER F: COVERAGES CERTIFICATE NUMBER: 281511 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. ILTR TYPE OF INSURANCE ADDL SUER POLICY NUMBER MMIDDIYYPOLICY FF M1DDIYY CY P LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE I s DAMAGE TO RENTED CLAIMS MADE OCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ __ N/A PERSONAL&ADV INJURY I $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY E¢ f LOC ' PRODUCTS-COMP/OP AGG $ OTHER: i $ I COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY I Ea accident _ i$ ANY AUTO I BODILY INJURY(Per person) I$_ ALL or SCHEDULED N/A BODILY INJURY Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $. EXCESS LIAB CLAIMS-MADE N/A AGGREGATE 1 DED RETENTION S ii $ WORKERS COMPENSATION I/�' STATUTE I ERH AND EMPLOYERS LIABILITY YIN �/ ANYPROPRIETOR/PARTNER/EXECUTIVE _ . A OFFICERIMEMBEREXCLUDED? NIA NIA NIA` R2WC940123 06/03/2018 06/03/2019 1 E.L.EACH ACCIDENT $ 1,000,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEd$ .1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below J E.L.DISEASE-POLICY LIMIT $ 1,000,000 N/A - DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only. Pursuant to Endorsement WC 20 03 06 B, no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Anatoli Sivitski ACCORDANCE WITH THE POLICY PROVISIONS. 222 Buck Island Road 6-8 AUTHORIZED REPRESENTATIVE West Yarmouth MA 02673 Daniel M, Cr— A CPCU,Vice President—Residual Market—WCRIBMA 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD �useu t m onwe al tht - e ''Ll.c.'.. -n P, C;-Stopt a, I } 'A S t �#f Ja k. o:n uctt, P CO% 06-0,40 y r b:.a ms , 5IM- i r a a n ; g OL t UTS :j "'E-STVR ! R JA awn. y�*F „�',- 1'': ./i' i l4p� $•""�"` A :off_ tl {� I 't 'r i 3 �'S h� �N' '1, J Y£ t F , e - i u v s r I A, ,r CAPE provementCOID Home!m CAPE COD HOME IMPROVEMENT TM 27 MILL.POND ROAD, WEST YARMOUTH MA 02673 (617) 710-1001 , (508) 469.0102 CAPECODINC@GMAIL.COM, www.RoOFCAPECOD.COM, WWW.FACEBoOK.COM/CAPECODHOME ---------------------------------------------------------------------------------------------- PROPOSAL 08. 15.2018 TO JOHN MORGAN LOCATION: 1 07-DOLPHIN LN, HYANNIS _ WE HEREBY SUBMIT SPECIFICATIONS AND ESTIMATES FOR - - MAIN COMPOSITION SHINGLE ROOF: ti • REMOVAL OF ALL EXISTING ROOFING AND FLASHING MEMBRANES TO THE PLYWOOD DECK SURFACE. ! • REPLACEMENT OF ANY DAMAGED OR DETERIORATED PLYWOOD DECKING AT AN ADDITIONAL COST. DECKING_- WILL BE REPLACED IN WHOLE SHEETS ONLY IN ACCORDANCE WITH RECOMMENDATIONS BY BOTH THE NATIONAL ROOFING CONTRACTORS ASSOCIATION(NRCA)AND THE AMERICAN PLYWOOD ASSOCIATION (APA). NEW DECKING SHALL BE APA RATED FOR STRUCTURAL USE. DECK FASTENING WILL MEET OR EXCEED LOCAL BUILDING CODE REQUIREMENTS'. • REPLACEMENT OF FOLLOWING FLASHING MATERIALS:STEP FLASHINGS, PIPE FLANGES,PERIMETER DRIP EDGE MATERIAL AND ALL SKYLIGHT FLASHING MATERIAL.ALL MATERIALS TO MEET OR EXCEED MANUFACTURER'S REQUIREMENTS. • ONE ROW OF ICE AND WATER PROTECTION MEMBRANE SHALL BE INSTALLED IN ALL VALLEYS AND AROUND THE CHIMNEY. • ONE ROW OF ICE AND WATER PROTECTION MEMBRANE SHALL BE INSTALLED ALONG ALL EAVES AND SHALL EXTEND PAST THE INTERIOR WALL LINE A MINIMUM OF 18 INCHES TO PROVIDE PROTECTION AGAINST DAMAGE FROM ICE DAMS. INSTALLATION OF ONE LAYER OF ROOFING UNDERLAYMENT ON DECK SURFACE NOT COVERED WITH ICE AND WATER PROTECTION MATERIAL. • INSTALLATION OF NEW,ARCHITECTURAL STYLE ALGAE RESISTANTCERTAINTEED SHINGLES.SHINGLES WILL BE INSTALLED IN STRICT ACCORDANCE WITH THE MANUFACTURER'S SPECIFICATIONS AND SHALL BE FASTENED USING SIX NAILS PER SHINGLE. ° • COLOR OF ROOF PENETRATIONS AND FLASHINGS TO BE CHOSEN BY OWNER. • INSTALLATION OF A SHINGLE-OVER RIDGE VENT.VENT IN THIS AREA IS CONTINUOUS AND WILL W CAPE COD HOME IMPROVEMENT'GUARANTEES THAT ALL COMPONENTS INSTALLED PROPERLY PLEASE FEEL FREE TO CALL CAPE COD HOME IMPROVEMENT TM WITH ANY QUESTIONS OR CONCERNS j PLEASE INITIAL THIS PAGE '4 s, Y CAPE CO t CAPE COD HOME IMPROVEMENT TM Homc Im rovemon 27 MILL POND ROAD, WEST YARMOUTH MA 02673 (617) 710.1001 , (508) 469.0102 CAPECODINC@GMAIL.COM, WWW.RoOFCAPECOD.COM, WWW.FACEBOOK.COM/CAPECODHoME PROVIDE MAXIMUM INTAKE VENTILATION FOR THE FULL ATTIC VENTILATION SYSTEM. • REPLACE ANY DAMAGE FASCIA-BOARDS OR RAKE-BOARDS AT AN ADDITIONAL COST. • ALL GROUNDS TO BE CLEANED UP ON A DAILY BASIS.ALL BUSHES,SHRUBS,AND FLOWERS TO BE PROTECTED. HOMEOWNER IS ASKED TO SUPPLY ELECTRICAL POWER IF NEEDED. OPTION 1 CERTAINTEED LANDMARK SHINGLES 50 YEARS NON-PRORATED TRANSFERABLE WARRANTY LABOR AND MATERIALS: $7,050.00 DUMPSTER: $450.00 TOTAL: $7,500.00 (OPTION:2 CERTAINTEED LANDMARK SHINGLES 40 YEARS PRORATED WARRANTY(10 YEARS NON-PRORATED PERIOD) LABOR AND MATERIALS: $6,250.00 DuMPSTER: $450.00 TOTAL 6 700.00 WE WILL.MATCH OR OUTBID ANY LEGITIMATE COMPETITOR CAPE COD HOME IMPROVEMENT TM IS PROUD TO PRESENT YOU WITH SUPERIOR 10 YEAR WORKMANSHIP AND SERVICE WARRANTY.THIS WARRANTY IS IN ADDITION TO,BUT RUNS CONCURRENTLY WITH ANY MANUFACTURERS'WARRANTIES. IT COVERS'ALL SERVICE CALLS RELATED TO WARRANTY REPLACEMENT AND/OR INSTALLATION ISSUES FOR THE FIRST TEN YEARS AFTER PRODUCT INSTALLATION CAPE COD HOME IMPROVEMENT TM GUARANTEES THAT ALL COMPONENTS INSTALLED PROPERLY PLEASE FEEL FREE TO CALL CAPE COD HOME IMPROVEMENT Tm WITH ANY QUESTIONS OR CONCERNS PLEASE INITIAL THIS PAGE i CAPE COD Home Improvement CAPE ,COD HOME IMPROVEMENT TM 27 MILL POND ROAD, WEST YARMOUTH MA 02673 (617) 710.1001, (508) 469.0102 CAPECODINC@GMAIL.COM, www.RoOFCAPECOD.COM, WWW.FACEBOOK.COM/CAPECODHOME PAYMENT TERMS: 50%AT DEPOSIT; 50%UPON COMPLETION. JOB IS ESTIMATED TO COMMENCE APPROXIMATELY 2 TO 8 WEEKS AFTER DEPOSIT RECEIVED WORK IS SCHEDULED TO BE SUBSTANTIALLY COMPLETED IN APPROXIMATELY 1 TO 2 WEEKS. ANY WORK ABOVE AND BEYOND THE SPECIFICATIONS WILL BE PERFORMED AT 56.00$PER MAN HOUR PLUS MATERIALS OR PRICED ON REQUEST.ALL ADDITIONAL WORK,INCLUDING TRAVEL TIME AND LUMBERYARD RUNS, MOVING ALL PERSONAL OBJECTS,FURNITURE,ETC. FROM WORK AREA,WILL BE SUBJECT TO EXTRA CHARGE. IN THE EVENT OF ROT REPAIRS, ROOF REPAIRS OR ANY RELATED WORK REQUIRING IMMEDIATE- ATTENTION,WE WILL PROCEED WITHOUT CUSTOMER APPROVAL. f CAPE COD HOME IMPROVEMENTTMM.WILL PROVIDE CLEANUP ON A CONTINUING BASIS AND ALL DEBRIS WILL-BE REMOVED FROM SITE(PROFESSIONAL CLEANING DOESN'T,INCLUDE).ALL PRODUCTS INSTALLED BY CAPE - COD HOME IMPROVEMENTTM WILL BE TO MANUFACTURER SPECIFICATIONS.ALL WORK WILL BE PERFORMED BY INSURED PROFESSIONALS. ALL MATERIAL IS GUARANTEED TO BE AS SPECIFIED,AND THE ABOVE WORK TO BE PERFORMED IN ACCORDANCE WITH THE DRAWINGS AND/OR SPECIFICATIONS SUBMITTED FOR ABOVE WORK AND COMPLETED IN A SUBSTANTIAL WORKMANLIKE MANNER. OWNER TO MOVE ALL PERSONAL OBJECTS, FURNITURE,ETC.FROM WORK AREA.ALL ITEMS AGAINST WALLS SHOULD BE CONSIDERED FOR REMOVAL DURING ANY EXTERIOR SIDING JOBS,ADDITIONS,ETC.TO GUARD AGAINST DAMAGE. IN THE CASE OF ANY ROOFING AND RIDGE VENTING,DUST AND DEBRIS SHOULD BE EXPECTED AND ANY ITEMS IN THE ATTIC SHOULD BE REMOVED:CAPE COD HOME IMPROVEMENTTM IS NOT RESPONSIBLE FOR ANY DAMAGES IF SAID ITEMS REMAIN IN PLACE. CAPE COD HOME IMPROVEMENTTM'I IS NOT RESPONSIBLE FOR ANY DAMAGES THAT MAY OCCUR DURING CONSTRUCTION TO LANDSCAPING OR ANY FINISH GROUND WORK,PLANTINGS,ASPHALT OR STONE DRIVEWAY, ETC. FLOWERS AND SHRUBS AGAINST HOUSE MAY NEED TO BE REPAIRED OR REPLACED BY HOMEOWNER. ANY ALTERATION OR DEVIATION FROM ABOVE SPECIFICATIONS INVOLVING EXTRA COSTS WILL BE EXECUTED ONLY UPON WRITTEN ORDERS,AND WILL BECOME AN EXTRA CHARGE OVER AND ABOVE THE ESTIMATE.ALL AGREEMENTS CONTINGENT UPON STRIKES,ACCIDENTS OR DELAYS BEYOND OUR CONTROL.OWNER TO CARRY FIRE,TORNADO AND OTHER NECESSARYINSURANCE UPON ABOVE WORK.WORKMEN'S COMPENSATION AND PUBLIC LIABILITY,IN ON ABOVE;WORK TO BE PLACED ON THE RESIDENCE AS A CONSEQUENCE OF THE CONTRACT.OWNER WHO SECURE THEIR OWN CONSTRUCTION-RELATED PERMITS OR DEAL WITH UNREGISTERED CONTRACTORS WILL BE EXCLUDED FROM ACCESS TO THE GUARANTY FUND. CAPE COD HOME IMPROVEMENT TM GUARANTEES THAT ALL COMPONENTS INSTALLED PROPERLY PLEASE FEEL FREE TO CALL CAPE COD HOME IMPROVEMENT TM WITH ANY QUESTIONS OR CONCERNS PLEASE INITIAL THIS PAGE/ CAPE COI3 Home fmprovement GAPE COD HOME IMPROVEMENT TM 27 MILL POND ROAD, WEST YARMOUTH MA 02673 (617) 710-1001 , (508) 469.0102 CAPECODWC@GMAIL.COM, WWW.RoOFCAPECOD.COM, WWW.FACEBOOK.COM/CAPECODHOME ______________________ ___-___---_____________________________---_________---_- COSTS OFF COLLECTION,INCLUDING ATTORNEYS FEES WILL BE RECOVERABLE,IN THE EVENT OF NON- PAYMENT. WE LOOK FORWARD TO WORKING WITH YOU: PLEASE CALL IF YOU HAVE ANY QUESTIONS. SINCERELY CAPE COD HOME IMPROVEMENT TM THIS CONTRACT NOT VALID UNLESS SIGNED BY ANATOLI"TONY"SMTSKI F X ACCEPTED BY ,enf� ;SIG DATE ACCEPTED B - �� 1`� v � Sl N DATE '0 0j. ACCEPTED BY SIGN DATE 17 CAPE COD HOME IMPROVEMENT TM GUARANTEES THAT ALL COMPONENTS INSTALLED PROPERLY PLEASE FEEL FREE TO CALL CAPE COD HOME IMPROVEMENT Tm WITH ANY QUESTIONS OR CONCERNS PLEASE INITIAL THIS PAGE ti The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations ' 600 Washington Street - Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): Address: ��"t4 tff po1�t 71d City/State/Zip: Phone#: 501 '(U 0/0 Z ire you an employer?Check the appropriate bog: Type of project(required): 1.LLJ I am a employer with 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers'comp-insurance comp.ins„rance.$ required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself[No workers'comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑Other comp.insurance.required.] *My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. .$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: q 7 0 -1 2_3 Expiration Date: 0�5 Go-I P Job Site Address: /0 7� �©/® L� City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number a d expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and pen of p ury that the information provided above is true and correct: Signature: Date: Phone#: 3v8�weq of Q 2 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#: i _ 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 certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit(license number which will be used as a reference number. In addition, an applicant that must submit multiple permitllicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do nothesitate to give us a call. The Department's address,telephone and fax number: The CommGnwealth of Massachusetts Dement of Industrial Aec-dents office of Investigations 600 Washington S Met Boston,MA 02111 Tel,4 617-7274900 ext 406 or 1-877-MASSY Fax#6.17-727-7749 Revised 4-24-07 wwwmass,.gav#dla 114E Town of Barnstable *Permit# 0361 3 3 y� Expires 6 months from issue date y Regulatory Services Fee D2 rSU BARN nstE, Thomas F.Geiler,Director 6 9. Building Division - �fD MA't 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 ONLY Not Valid without Red X-Press Imprint Map/parcel Number r Property Address r EIR-es�ential Value of Work D 0 o Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address I ell �1 �i C ) e r'1 I S Contractor's Name__!�` Telephone Number Home Improvement Contractor License#(if applicable) ❑Workman's Compensation Insurance Che -PRESS am aproprietor PERMIT X'(A [_1 tri he Homeowner JUN 6 ❑ I have Worker's Compensation Insurance 2008 Insurance Company Name TOWN OF BARNSTABLE 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) F] Re-side e lacement Windows/doors/sliders.U-Value ��,QV p (maximum .44) *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 is required. Q� ; t°11u SIGNATURE: ZC :g IN 9- NAr HE Q:Forms:bui l di ngpermits/express Revised 123107 Town of Barnstable IHE Regulatory Services saxtasTwart Thomas F. Geiler,Director y MASS. 1639. Building Division �TFD eta Tom Perry,Building Commissioner . 200 Main Street, Hyannis, MA 02601 v my.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: U u l h 1 0 number street llage "HOMEOWNER„.T < JblO�� A—\-k h name ^� home ph e# work phone# CURRENT MAILING ADDRESS: ^� Q 1 S .✓1✓11 $ 1/ rn b � � 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 Iicense,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) 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 requiremmt�and that he/she will comply with said procedures and ' requir - ---------F c Si ure o Homeowner Approval of Building Official ' Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the , State Building Code Section 127.0 Construction Control. 'HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 1 o9.1,.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 fomJcertification for use in,your community. Town of Barnstable ti Regulatory Services qa"MASS. ` Thomas F. Geiler,Director �ArF059. Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-962-4038 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 behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) r Signature of Owner Date Print Name If Property Owner is applying for permit please complete the Homeo"ers License Exemption Form on the reverse side. ,per The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 • www.mass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Lezibly Name(Business!Organization/individual): t n A Admss: to CJ s �l S 0 V City/State/Zip: - Phone-M !, ZS 5 - ea I Are you an employer? Check the appropriate box: Type of proiect(required): 1. I am a employer with 4. I am a general contractor and I 6. ❑New construction Mr. full and/or part-time).* have hired the sub-contractors euvwf2 am a sole proprietor or partner- listed on the attached sheet 7. El Remodeling ship and have no employees These sub-contractors have g, �Demolitipn for me in employees and have workers' working �Y���• in�tmrancC.$ 9. ElBuildmg addition [No workers comp.-bumrance comp ] 5. We an a corporation and its 10.0 Electrical repass or additions am a homeowner doing all work officers have exercised their 1 LEI Plumbing repairs or additions myself[No workers' comp. right 6f exemption per MGL 12❑goof repairs insurancz require&]t c. 152, §1(4),and we have no employees. [No workers' 13.❑Other comp,insurance required.] •Any applicant esat elmealz box#I must also Ho out the section below showing thca wakes'compensation policy infartmmatim-L t Homeowners;who submit this affidavit indicating 9sry mm doing an work and then hire outside contmactnrs must submit anew affidavit indicating such. tconhactors that check this box amst attached an additional sheet showing the name of the sub-conractma and slate whether or not thosb entities have employees. Nthe sub-contractors have employees,they must provide their wcake s'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the polity and job site information. Insurance Company Name: - Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State 4- _ 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 tip 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 MOM a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of _ Investigations of the WA for insurance coverage verification. I do her certify der the pains an of perjury that to information provided above�Irue Si e. Date• _ Phone#: Official use only. Do not write in this area,tb 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 budding 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)stales`Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of comphi nce 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,it necessary,supply sub-contractors)name(s),addrrss(es)and phone numbcr(s).along with their certificates)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 B;advised that this affidavit may be submitted to the Department of Industrial Accidents for con5moation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town drat 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 permittlicense applications in any given year,need only submit on;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 io 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 lice 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,tzlephone•and fax number. The C6mmonwealth of Ma=chus u Dgwtmeut of Industrial Accide nts office of Investiptions 600 Washington Street Boston,MA 02111 W. #617-727-4940 W 4-06 or 1-977 MASSAFE Revised 11-22-06 Fax#617-727-7749 www.mass.gov/dia ' ` ;/Assessor's Office(1st floor Map (G' Parcel Peimit 4, ,,Conservation Office(4th floor (8:30-.9:30/1:00; 2:00) C10TcA Date Issued /0 - ?,a - /S Board of Health(3rd floor)(8:15 -9:30/1:00-4:45)0 /of " 04 Fee 5 c/0 /Engineering Dept. (3rd floor) House# m Planning Dept. (1st floor/School Admin. Bldg.) MA. 7. Defin' ve P n Approved by Planning Board _ . TOWN OF BARNSTA MONMkrAL CODE AND Building Permit Application r,,/Project Street Address. 0� (��(�lyj �'► _ " t + Village M4 awts1 ^�' Owner b y P V A ,) 1 X ddress 47- y left j fib,At 1",Ar ,Telephone 7 -• qFI—0 77 , ��W't Request �.r/Z '•``� ' , r First Floor square feet Second Floor - square feet stimated Project Cost $ I�` r Zoning District Flood Plain Water Protection Lot Size 100)( 134) 13 it" 5 Grandfathered ? Zoning Board of Appeals Authorization Recorded Current Use Proposed Use Construction Type add Commercial Residential Dwelling Type: Single Family Two Family Multi-Family Age of Existing Structure 3 NRS Basement Type: Finished Historic House Unfinished Old King's Highway Number of Baths f No. of Bedrooms 3 Total Room Count(not including baths) `7 First Floor J Heat Type and Fuel Central Air Fireplaces Garage: Detached Other Detached Structures: Pool Attached Barn None Sheds Other Builder Information Name ( ,(Z-1'LD��i Telephone Number Address License# Home Improvement Contractor# Worker's Compensation# NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS PROPOSED STRUCTURES ON THE LOT. ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO t SIGNATUREV� DATE /6 LQ 7 - BUILDIN6ERMIT DENIED FOR THE FOLLOWING REASON(S) FOR OFFICIAL USE ONLY PERMIT NO. - DATE ISSUED MAP[PARCEL NO. ADDRESS VILLAGE _ OWNER DATE OF INSPECTION_ : f - FOUNDATION I�°� vA FRAME "V INSULATION FIREPLACE ELECTRICAL: ROUGH `": FINAL PLUMBING: ROUGH FINAL GAS: t ROUGH'_ 1 FINAL FINAL BUILDING DA: CLOSED OUT es4 t ASSOCIATION PLAN NO.,, • + } z OfjNE► The Town of Barnstable O� BARMARSA LE. MASS 9` Department of Health Safety and Environmental Services 0 i639' �0 % Building Division 367 Main Street,Hyannis,MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner Inspection Correction Notice Type of Inspection Location � �1� l v Permit Number C Owner S `G t Q 4 A Builder C- One notice to remain on jobsite, one notice on file in Building Department. The following items need correcting: 1 �G Cc S a0A (� ► ,�Svc L ���� Please call: 508-790-6227 for reeinsP ection. Inspected by Date + r .oFtHE r � The Town of Barnstable BAE. - Department of Health Safety and Environmental Services 7 MASS. g i639. �0 'QED ru+0. Building Division 367 Main Street,Hyannis, MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner Inspection Correction Notice Type of Inspection Location 0q V( Permit Number Owner Builder One notice to remain on jobsite, one notice on file in Building Department. The following items need correcting: 0�Y- L Please call: 508-790- 2;27 for reeinspection. Inspected by Date 12` `OFIME A The Town of Barnstable 98ARMSTABLE.MA o` Department of Health.Safety and Environmental Services SS. 0 i6yq. �e 039. Building Division 367 Main Street,Hyannis,MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner Inspection Correction Notice Type of Inspection IJ Location ,O N� Permit Number = ( C Owner l_..,J (C)Q I tQ ( Builder One notice to remain on jobsite, one notice on file in Building Department. ,The following items need correcting: To -ZIA =Luot2 �3) � Le UID �--CS sy Y-i N-) -Z e-11` c-� Please call: 508-790-66227 for rreein�spection. Inspected by J r�h--'-' Date 0 �o� r 7 WE s�E. A. FOR DATE TIME IM C ;I�H(3NE0 OF t�ET�UfiN�il PHONE YLtU1�CA L AREA E NUMBER EXTENSION MESSAGE f?LEAE CALL;. QUILL CA,£L� Q � Q �// �c AGA(Al'�•.�,' > z CAlU(E TO, JO 71 1N�MS Tfl z �e�SEE'Yfl[� r SIGNED TOPS I@ FORM 4006 NOTES � t • 1 I eAj OAe- ,eX��in �0►ye �/9V.S�R��,a� , � _ � �'Il JXiO Iveboa91 I� bl o� �t PIS aD �� x —3Iq►�PW wD`� ik�u I 9X9716. 16o.e. IX 10'' 4 aXq • 1 ax8,, a� i tip' i Ten �y l Flo o oz cc> NQ v. v r � +` The Cummunwealth of Massachusetts - _'•.�y Departnrcrnt of Industrial Accidents 'y 011�ceol./m�esflgatloas L �: ... . 600 11'ashingion Street Boston.Alas 02111 Workers' Compensation Insurance Affidavit .,.. ARpa a .,.,,.....it..,,.. Pleace PRIN' ey name Ji'r��U V Jlir��ibvAnn� �nc•ltion 0-7 0O 4 }1111 y n I am a homeowner erforming all work:myself. I am a sole proprietor and have no one working in any capacity rl 1 am an employer providing workers' compensation for my employees working on this job. company nome! addretc• ' nhnnefh. insurance co nolia# I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors lasted below who have the following workers' compensation polices: comliany Citx: phone c policy# '- ::...:,..,,ry..•sue.-�s-�►r•r��y •�s�s,+��...�,d r_:.� -- •"'ter m nv n e• phone On -�----- policy# :Attach additlonaa'sheef itneeeasa a•yw:S:••`�'�^A'-"='��';`^sf�•'"-�"'�r`.:"�''i'{•� •� .. Failure to:eenrc coverage as required under Section 25A of A1GL 152 can lead to the imposition of erimiwl penalties of a fine up to SISOOAO and/or une years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of S100A0 a day against me. 1 underrtand that a copy of this statement may be forwarded to the Off ce of investigations of the D1A for eoeersge verification. t do hereAr cerify under the pains and penalties of peduly that the information provided above' nue and correct C�iSienature r® 4 J' print name -S i J--V o i% I / 1s �[/�[I Phone# f`7 — 07 ';;; • r ofricial use onir do not write in this area to be completed by city or town ofildid L1tc permitilicense# r nuiiding Department (3Ucea3ing Board response is required 13Seleetmen's Office �liealth Department phone#t rJOther banned b95 P1A1 The Town of Barnstable Department of Health Safety and Environmental Service Building Division 367 Main Street,Hyawds MA 02601 Ralph Cst = O&ca 508-790.6227 Building Commis; F= 508-775 3344 For office use only - - Permit no. • Date AFFIDAVIT HOME SWROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERKLT APPLICATION MGL G 142A requires that the-r=011struaron,alterations;renovation,r*d4 mpdern�On,conversion, irnprvvemed,.removal, demolition. or amstr'uc Lion of an addition to any owner o=zpied building containing at least one but not more than four dadling units or tO strac =which are adjacent to such residence or building be done by registered oozaractors.'With certain cmeptiOnS,along with other requirements I Type of Work- T enA i Z Vew Lid &A5 Est.Cost o ,,,,XAddress of work: )0% ���.)o La fi Anm)j 2 a Oa er.Name: < i 1►i b b V )l7)6 Lal p Date of Permit Application: I herein•certify that: Registration is not required for the following rcason(s): Work cccluded by law _ _ob underSLOW �waff polling own Permit Notice is hereby gi<m that: CONTRACMRS OWNERS PULLING THEIR OWN PERMIT OR DEAUNG r NOT HA (ASS TO 'III FOR APPLICABLE HOME IMPROVEMENT WORK Do ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c 142A SIGNED UNDER PENALTIES OF PERMY I hereby apply for a permit as the agent of the M*ner:' Ao L I v On No. D to Contractor name R `--"OwPC2 0 TOWN OF BARNSTABLE BUILDING DEPARTMENT HOMEOWNER LICENSE EXEMPTION Pl ase print. JOB iocATloN a �i� n41LIA4,4jStpook 'Number Street address Se ion of town HOMEOWNER" Name Home phone Work phone " PRESENT NAILING ADDRESS 7 q C/00 City/town State Zip code: The current exemption for "homeowners" was extended to include owner-occupi. dwellings of six units or less and to allow such homeowners to engage an in dividual for hire Who does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER: Person(sj who owns a parcel of land on which he/she resides or intends to r side, on which there is, or is intended to be, a one to six family dwelling attached or detached structures accessory to such use and/or farm structure A person who constructs more than one home in a two-year period shall not b considered a homeowner. Such "homeowner" shall submit to the Building Offi on a form acceptable to the Building Official, that he/she shall be respons for all such work performed under the building ermit. (Section 109.1.1) The undersigned "hom*eowner" assumes ,responsibility for compliance with the Building. Code 'aad other applicable codes, by-laws, rules and regulations. The undersigned "homeowner" certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requiremen- and that he/she will comp with said procedures and requirements. HOMEOWNER'S SIGNATURE APPROVAL OF BUILDING OFFICIAL Note: Three family dwellings 35,000 cubic feet, or larger, will be requirec to comply with State Building Code Section 127. 0, Construction Control. HOME OWNER'S EXEMPTION " The code state that: "Any Home Owner performing work for which.---a:.bnild. permit is required shall be exempt from the provisions of this section (Section 109. 1. 1 - Licensing of Construction Supervisors) ; provided tha- Home Owner engages a person(s) for hire to do such work, that such Home shall act as supervisor. " Many Home Owners who use this exemption are unaware that they are assu= the responsibilities of a supervisor (see Appendix Q, Rules and Regulat! for .licensing Construction' Supervisors# Section 2.15) . This Pack of awz often results in serious problems, particularly when the Home Owner hire unlicensed persons. In this case our Hoard cannot proceed against the inlicensed person as it would with licensed Supervisor. The Home-djqfieS: as supervisor is ultimately tesponsi.ble. To ensure that the Home Owner is fully aware of his/her responsibilities communities require, as part of the permit application, that the Nome 'Ow certify that he/she understands the responsibilities of a supervisor. O. last page of this issue is a form currently used by several towns. You i care to amend and adopt such a form/certification for use in your common; i _ 1 ' ,.•�rsa"T+i 7w, I1 COMMONWEALTHDEPARTMENT OF PUBLIC SAFETYOFONE ASHBORTON PLACE Mssssobssatts smeeffifd/eA MASSACHUSETTSBfOSTON'ANA 02t08 "8!Op�ftesi4l_ LICENSE CAUTION EXPIRATION DATE CONSTR. SUPERVISOR NS 0 4/2$/19 9 b FOR PROTECTION AGAINST RESTRICTIONS -EFFECTIVE DATE LIC-NO. THEFT;PUT RIGHT THUMB NONE 06/30/1993 0038.13 PRINT IN APPROPRIATE S I L V I O V D I G I O V A N N I BOX ON LICENSE. 49 GL EN N R D BLASTING OPERATORS . BELMONT MA 02178 MUST INCLUDE PHOTO_ PHOTO(BLASTING OPq ONLY) F "'•� v lJ NOT VALID UNTIL SIGNED BY LICENSEE AND OFFICIALLY 1 I� HEIGHT: STAMPED-OR-SIGNATURE OF THE COMMISSIONER z " ' THIS DOCUMENT MUST BE GZ.cY I'EN Q4� SIGN E IN ULL ABOSIGNATUgELIN CARRIEDON THE PERSON CIY SIGNATURE OF LICENSEE THE HOLDER WHEN EN- OTHERS-RIGHT THUMB PRINT GAGED IN THIS OCCUPATION. F' .h1 WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 8`9 06 00 (Ed. 4-84) POLICY INFORMATION PAGE ENDORSEMENT f his endorsement ;.hianyes the policy to which it Is attached effective 01) the Ince0tlon date of;.he policy unless a different date is indicated belcw ;The 1pliowimg''attdCr,i'r�Clduar,"need be Eornpjr"(ed onry wne'-fhs erdorse-rerit,,iss�e0 This endorsement, effacIlve on 111 1/94 at 12.01 A.r,_1, standard time, fcrms a part of (DATE) Policy No. WC4000048-00 Endorsement Na l " of the Savers Property Casualty Insurance Compamj NAME C* GOf�?P,ANY) Issued to. OiGlvvanni Brothers, Inc. Pietriium (it Tiny) Authc;izeo Repseeentat;vr The toHowlnp Item ( j Insured's Name (%IVC 89 Ut3 G1 Ad-dress{'!.'C 89 O6 06j ( j PoIjoy Number (WC 89 06 021. ( j Fxne race "1Udi�Ca;iG (�'^y` 89 04 c}L) j j Effective Data (vVC lib 06 03t I )Agent's Name CHIC: 89 06 C 7j ( J Lxpiration Date (°,')C ay Ud U4) ) Chance In LoCa ( ; Form W ' 00 04 0 Codes is changed to read' 1. Employer's FE.IN Is added: `04-2301848 Edition Date of fori>> 01 6d WC amended:to read (9-94 in lieu of(6i94) Edition Date of. form 09 t w^`;;arnende o lira: f i;.94, Endorsement VVC;10 U3 0 'rs added Endorsement WC'20 C6 02 is deleted Lndorsen'jent %AV U U"1 01 is•�Jdea Endometnenl VVC U o,; 14 15 aCided e ALL-OTHER POLICY TERMS AND CONDITIONS REMAIN UNCHANGED. Cepyrlght 1titl4 Neu ;iy. ounul on.i Qnpe tsaiion Insurance.- Zf 8/95 loT b�QyOFTHE TOWN OF BARNSTABLE STABLX N0 ABL O 39, INSPECTOR a M 'Ar- "I BUILDING APPLICATION FOR PERMIT TO ...I....... ..... ................... TYPE OF CONSTRUCTION ............ ............ ..............1972- TO THE INSPECTOR OF BUILDINGS: x The undersigned hereby applies for a permit according to the following information: Location ..... `ti.l..Yl......�r�.V.�' 1 4,04�..... ( .................. Pro osed Use .......... 2..�Lz.................................................................................... .......................... .. ZoningDistrict ........................................................................Fire District .................................................,............................ .Name of Owner ...............Address ... 3.e6w.o o/- . 16'4,7, Name of Builder .....0V...........................Address ... ....... . .... ...................... Name of Architect ...—Address ........... .. ... Number of Rooms ...... 6.......................................................Foundation .......................................... l •aC' Exterior ........ .. .. .. ...........Roofing ... ........... Floors .... .........................Interior Heating ............... ........................................................Plumbing ........ . ......... ......................................... -kez Fireplace .................. ........................................o.....Approximate Cost 4 ................. Definitive Plan Approved by Planning Board -------------—-—-----------19--------- Diagram of Lot and Building with Dimensions SUBJECT TO APPROVAL OF BOARD OF HEALTH ud 11) (9 M LLj 0 < W a. I-- (f) t z Ej a z < Ld W > < = 0 A( co < OU- o- ILO 1.00 LL. LLI 0- ,% 0 V) < I Z (n >: < Ld CL LL, LU < r F" U-) Z M `�� C� `� ul Ld Lij < C9 Lij < V) O Z, 6' CL < IX < z 0 < Z I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Pelf Name ...j(, ...�-k..... . . .. .................t........... E,< 7- Yeraco, Christ F No 14?67 one story f ...... ......... Permit for .................................... f i single family dwelling i ............................................................................... Location ..........Dolphin Lane........................... West Hyannisport Owner Christ Yeraco ! f ................................................................. Type of Construction frame .......................................... I ....................................................... .................. i Plot ........................ . lot ....... 4.................... April 21 72 ! - Permit Granted ........ r .......... .............19 Date of Inspection� �` ........1 91 / s ' Date Completed ....../../. ... '3 ...7`....19 I Ile �J L PERMIT REFUSED , J /`'� fl, ................................................................................ C! f ............................................................................... i ............................................................................... Approved ................................................. 19 ............................................................................... ............................................................................... 1 t O d W 1� OF BARNS M�� TA B L E 00,0� i639• - �f�YAY a• BUILDING . INSPECTOR APPLICATION FOR PER/NIT TO / TYPE - ,..... ............. S7`� yf E OF CONSTRUCTION ";-�!%';... . r �'.�. -. ...... .... .. .. . i�. , .� ....... .. ;. TO THE INSPECT � } ......undersigned�- sig d hereby 197 -� y applies for a pe 'I� Location „�,v... / l yy�� rmit according to he following info '(`� Yl !•.`..V.Qf .. s .l.... rmation: /O� :,4 Proposed Use .... .... .Y1ti!(. ,a ^� Zoning District , .I,�' Name of Owner .��/( � •�•�5.f'. .. ..�. .. .. ........ ...... ....Fire District Name of Builder Address ... ,( • �� � tom......... .,.. ...................Address Architect Name of Arc ..� dress ..... ..... , Number of Rooms ...............................Address ............ ............ Z .......................... ..... ...... ...... Exlerior .......................Foundation ................... F 'elf.. .Floors ......Roofing `... ... .... .fv14�.Heating .........................Int erior .........•.•...... ............................................ ..............•......• Fireplace .. � ............ Plumbing J ........ . ..... ,. ..... .... .. Definitive Ian Approved by Planning Board Approximate Cost •• •• .... Diagram of Lot -----------------and Building n9 with Dimensions SUBJECT TO APPROVAL OF BOARD — �----- OF HEALTH -� O it oo w � oo� zJ WjyLL � � W a Li 8 e LLI Lr / . r_ 11 Ix Q w Ui i_. � � _ � 7 Uj Uj Q oA O ) z � `S I CL of � J 1- a W I__ _ Z p ¢ loo, I hereby Agree to conform construction to all the Rules ' . and Regulations of the Town Of Barnstable regarding the above Name ...,L� r �" .�-t