The URL can be used to link to this page

Home My WebLink About0100 ESTEY AVENUE �6 A-v6- . 'I,I :Commonwealth of Massachusetts Sheet Metal Permit Map a Parcel Date: PER!►►.o";ermit:# Estimated Job Cost: $ I 0 Q y '� � " � LC t¢ Permit Fee:. Q� Plans Submitted: YES, N Plans Reviewed: YES NO O'Fe Business License# �� Appc� iLnse# �� Business Information: Property Owner/Job,Location.Infor�iation: Name: Name: �— e Street:` O ('S S Street: o D CAS d� City/To-;Yn: ' �� V � CityLTown: A.Xytt Telephone:. . aj-. Ln 3 Y t' Telephone: ln�M- CY 3 Photo I.D.required Copy of Photo I.D. attached: YES NO1 staff Initial S=1/lYl-l-unrestricted.license J-2/M-2-restricted to dwe11ings.3-stories or less and commercial up to 107000 sq. ft./2-stories or less Residential: 1-2 family Multi-family Condo/Townhouses Other Commercial: Office Retail Industrial Educational Fire Dept. Approval Institutional_ Other Square Footage: under 10,000.sq. ft. over 1:0,000 sq.ft. Number of Stories: Sheet metal work to be completed: / New Work:X Renovation: HVAC Metal Watershed Roofing Kitchen Exhaust System i Metal Chimney/Vents Air Balancing Provide detailed description of work to be done: R, INSURANCE COVERAGE: 1 have a current liability insurance policy or its.equivalent which meets the requirements of M.G.L.Ch.112 Yes❑, No ❑ If you have checked Y_W,indicate the type of coveraage'by checkmg the appropriate box below: a , A liability insurance policy Other type of ,n tiindemnity! Bond ❑ I OWNER'S INSURANCE WAIVE :1 am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Massachusetts General Laws,and that my:signature on this:permrt application waives this requirement _ 1 Check One Only I Owner ❑ Agent ❑ I Signature of Owner or Owner's Agent I By checking this box[],I hereby certify that all of the details and Information I have submitted(or entered)regarding this application are true and accurate to the best of my knowledge and thafall sheet metal work and installations performed under the permit issued for this.application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. IDuct inspection required prior to insulation installation:YES NO i Progress InsIlections Date Comments i Final.InsRection Date Comments i I Type of License: 3y Master Title ❑Master-Restricted [ ,ity/Town . ❑Joumeyperson. Signature of Licensee 'ermit.# L ❑J.ou meyperson-Restricted License:Nurnber:. :ee$ Check at www,mass.gQvldnl nspector Signature of Permit Approval . L COMMONW�/ L�H O� MASS"'.A, TTS 3 { SHEEN METgLWORK�ERS:` � � ISSUESTHE FOLLOWING LiEENSE i AS A NfASTER UNRESTR I CTED�s. �s" LLlKE ;h 30 ME L I SSA [?R tr ' YARMOUTH MAx'026 �IJ it • v .COIVIiiIIONUVEALTHrcO�,,IVI{, 1SSiCHUSETTS P Mil® „ � SHEgET fit..... ORKERS ISSUES 3THEF;OLLOWyhIaIG l £EHSE Y a MASTER UNRESTRIaCTE,Dt :� LUKE $ CYR R 'r .r� a7 is 30 h1ELIS5A DR- r t + Ma 402673 ��463 30;684 r t Mike Phillips 100 Estey Hyannis,MA' A&L Heating Cooling& Home Improvements I would supply and install: Gas Fired warm air Heating and Air Conditioning 1- Carrier 59SP5A060E17--14 AFUE 96.5% high efficiency furnace w/A/C coil installed located in the basement serving the first floor on one zone 1-Carrier 24ABC636AO0316 SEER outdoor condenser with pad,drain, and line-set included. * Insulated galvanized duct system designed to maintain 70 degree temperature in zero degree weather with 15 mph winds and to-maintain 15 degrees below outside air temperature in summer. * electrical work included. ' * Gas piping included: * permits & inspections included. * 10 year warranty Heating and Air Conditioning Cost:W" All heating and air conditioning items to be installed in a neat,workmanlike'manner and to be covered.by the usual 1 year guarantee against defective materials. Thank you for considering A&L for all your heating and air conditioning needs. Please feel free to contact us if we can answer any questions or be of any assistance. 508-360-8340 Sincerely, Luke Cyr, A&L Heating Cooling&Home Improvements. The Commonwealth`of Massachuseds Department oflndustrial.Accidents Office of Investigations .600 Washington Street Boston,.MA 02111 www.mass.gov/dies Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Let=ibly Name(Businessloiganizatim4ndividual): L--U\kL , Address: t-',\R-U-� SSg f 1✓� City/State/Zip: I h Phone.#: J O 3 Are you an employer?Check the appropriate boa: Type of pioject(required):; 1.❑ I am a.employer with •4. [,] I am a general contractor and I employees(full and/or part-time).* have hired&e sub-contractors 6. []New construction . 2.❑ I am a'sole.proprietor or partner Iisted.on`tlie'atisohedsheet .7. ❑Remodeling: ship and have.no employees Thesesub-contractors have 8. ❑Demolition worIcing ,.or me in,any capacity employees and have workers' , t: 9. ❑Building addition [No workers'comp.insurance comp.insurance, , Electrical repairs or additions required] 5. 10. a¢ We are a corporation and its ❑ ep ` 3.❑ I am a.homeowner doin all work :officers have exercised their l l.❑Phmtl*repairs.or additions ' inyself.[No workers'comp., right of exemption per MGL I2.❑Roof insuuance required.]t c. 152,§1(4),and we have no . employees.[No:workers' 13% Other- �. comp;insurance required.] OAny applicant that checks box#1 must also fit out the section below showing their woilaers'compmsation;policy-infotamtion, . t Homeowners who submit this affidavit indicating they are doing all work and rhea hire outside contractors must submit a new affidavitmdicatmg such. tCont actors.that check this box must attached an additional sheet showing the uz=of the sub-contractors acid state whether or not those entities bave ernployees. If the sub-contractors have employees,they mustpravide their worlmrs'comp.:policy n®ber.. I am an employer that isproviding 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 MCTL 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 statemmit'maybe forwarded to the Office of Investigations of the DIA,for insurance coverage verification. Idoherebycertzynthepains-andpenalties,ofperjurya th ifomop drcLji Signature, Date: Phone#: Official use orrly. Do.:not write in:th,s;area,:tb`fie completed by co.,or town of7 al, , Ciity.or Town: PermittUcense# •Issuing Authority(circle one). A.Board of Health.2:Building Department.3,City/Town Clerk 4..Electrical Inspector 5..Plumbing Inspector 6.Other Contact Person: Phone#: f i t aAV Town of Barnstable Permit# ITyv �;� "ti ti Expires 6 month ror 'ss:� ��" Regulatory Services Fee v P��Ull Thomas F. Geiler,Director NSTP�BLE Building Division Tom Perry,.CBO, Building Commissioner 200 Main Street;Hyannis,MA 02601 wwtiv.town.barnstable.ma.ias Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION' - RESIDENTIAL ONLY Not Valid without Red X Press Imprint Map/parcel Number Property Address C?e e— residential. Va.lueofWork Minimum fee of$25.00 for work under S6000.00 Owner's Name&Address ' JAI Wit/ - Contractor's Name �� 60e✓17 I AIC .-zf G°�`� l �'�/6— Telephone Number J e e 7 A, Home Improvement Contractor License#(if applicable) / GC� Construction Supervisor's License#(if applicable) Ca(Vorkman's Compensation Insurance Check one: ❑ I am a sole proprietor am the Homeowner have Worker's Compensation.Ins ance Insuranc man Name'e Company Y Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) [/e-roof(stripping old shingles) All construction debris will be 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 cope Home Im vement Contractors License & Construction Supervisors License is SIGNATURE: . G1 ..,.......,,... ......_.r..r__�_ cvnoccc .4-, - i The Commonwealth of Massachusetts Department of Industrial Accidents ' Office of Investigations , 1 600 YYashington Street Boston, MA 02111 rvyvw.inass.gov/dia Workers' Compensation Insurance Affidavit: ]Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Le ibl Name (Business/Organization/Individual): ( "et d Address: P) f City/State/zip: r� Phone #: YO� 7Z6 G U �C �� o AFIreu an employer? Check th�ppropriate box: Type of project(required): am a employer with S 4. ❑ I am a general contractor and I 6 ❑New construction employees (full and/or part-time).* have hued the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition workingfor me in an capacity. employees and have workers' Y9, ❑Building addition [No workers' comp. insurance comp.insurance. required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself,.[No WorkeT5'_cQznp,....,____._......... __.. right of exemption per MGL ❑Roof.repairs.........,. t ... __ _ 12. insurance required.] t c. 152, §1(4), and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box 41 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 isproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins. Lic.#: Expiration Date: Job Site Address: dD fsf 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 DIA for insurance coverage verification. I do hereby certi pains and ties ofperjury that the information provided above is true and correct. Signature: Date: /•0 Phone# Official use only. Do not►vrite 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/Totivn Clerk 4.Electrical Inspector 5. Plumbing Inspector 6. Other r . s n.,_..>..,. 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 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 ^'Tmembers or partners,are not required to carry workers compensation unsuirance. If an LLC or LT P 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 permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town maybe provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The 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 4-24-07 www.mass.gov/dia IsfizndSiding and Roofing a division of (CT Construction, Ins 31 Wanni Circfe Centeruiffe, -1/tA 02632 Mike Phillips April 16,2010' 39 Howells Rd. Belmont,Ma.02478 Re: 100 Estey Avenue Hyannis,Ma. We are pleased to submit the following specifications and estimates for reroofing. Remove existing asphalt shingles and flashings. Install aluminum drip edge and pipe flashings. Install 3ft. Winterguard ice shield to eaves,valleys and interwoven with flashing on cheeks, skylights and chimneys. Install 15 lb roofers select paper to remaining roof areas. Install 50 yr. Certainteed Premium Landmark Woodscape architectural grade shingles. Install Certainteed Shinglevent II ridge vent to all ridges. Clean up and haul away debris to landfill. We hereby propose to furnish material and labor - complete in accordance with.the above specification, for the sum of: $5,900.00 For partial removal of kitchen ceiling and insulation.Installation of new insulation and sheetrock, as well as finishing and painting. $1,200 to $1,500.00 Terms: No.deposit required. Payment in full is due upon completion. All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard.practices. Any alterations or deviations from the 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. Owners to carry fire,wind damage and other.necessary insurance. RLT Construction,Inc. carries General Liability and Workman's Compensation Insurance. Certificates of Insurance provided upon request. . ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are satisfactory and hereby accepted. You are authorized to do the work as specified. Payment will be made as outlined above. Date of Acceptance:c'� h�lIU Signature Start Date: Signature ��.. il�itiachu5ettsurtnrent of Pud�lic-Safety 9 Bo to d of Building Rcgulations and St ind,-i-& Construction':Supervisor Specialty License _ a t License: CS`SL 99910 4 Restricted to RF,WS e` BONNIE 'TAYLO.R 31 MANN'I CIRCLE �CFNTERVILLE MA:02632 EXp*ati'on: 10/26/2011 :C ununi§siuficy Tr#r 99910: i � i� � � ' ✓�ie L�anvrrcarzcuP�.o�./l�Lcr�,4ac�it�6 , Office of Consumer Affairs&Business Regulation ..HOME IMPROMEMENT CONTRACTOR t Registration 134286 Expirat on 10122/,011 Tit 293257 TYPe +RLT GONST. INCt DBAISU -D'SIDING&ROOFIN I RCQNNIE.TAYLOR pi �. 5) 31.MANNCCIRCLE CENTERVILLE MA 02362 P ;: Undersecretaryy r r License or registration valid m 'for dmdul.pse only before the expiration date.•If found return to: Office of Consumer Affairs and Business Regulation , 10 Park Plaza ySuite 5170 Boston;MA 02116 - •ter, _ '\ Not valid with gnature ®® 04/22/2010 09: 05 50884204474 PALUHB0 .INS COTUIT PAGE 01 ��R� DATE(MMIDDl(YYY) /� ®® CO CERTIFICATE OF LIABILITY INSURANCE 4/21/2010 PRODUCER (508)428-1943 TAX: (508)420-4474 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION William Palumbo insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 4527 Falmouth Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Cotuit MA 02635 INSURERS AFFORDING COVERAGE NAIC# ------- . . - -- ---- - - -...... ..._.....----- - - ................ ...._.�__—_... INSURED INSURER A;Travelers 39357 -..__.._.. .......... RLT CONSTRUCTION INC. INSURER B;Guard Insurance Co 31 MANNT CIRCLE INSURER 0: INSURER D: CENTERV1,LLE MA. 02632 INSURERE: 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 OFSUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. --- ..... _ ....._ ---- INSRADD' �� --�-•--------- - - - ------ POUCY EFFECTIVE-. POLICY EXPIRATION ------ - .. ..... GF INSUJ�QNCE POLICY NUMBER DATF "'A'11D/YYYYI I DATE(MM/DDIYYYYI LIMITS GENERALLIAS0.ITY EACH OCCURRENCE SNTS 1.1000 r 000 - 15AMAGE TO RE . ... x COMMERCIAL GENERAL LIABILITY - PREMISES(EA A —i_-— CLAIMSMAOE �£IOCCUR'680B476N705 8/1/2009 8/1/2010 MEDEXP(Any on9peraon) $_—_ 5,000 --- ------- ------ PERSONAL&ADV INJURY ------- GENERAL AGGREGATE. S •--- 000'000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP19 AGG $ 2,000,000 X POLICY PRO- F] LOC AUTOMOBILE LIABILITY, --- COMBINED S(NGI.F LIMIT ANY AUTO (Ea eccldeni) — _ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Par person) HIRED AUTOS -- BODILY INJURY NON-OWNED AUTOS - (Par aaldont) 5 t i —.-- ----•---- I - - - P9p a Cda 1'AMAGE GARAGE LIABILITY AUTO ONLY-FA ACCIDENT- $ — ANY AUTO EA ACC a - OTHER THAN --- -- AUTO ONLY: AGO _EXCESS t UMBRELL_A LIABILITY - _ - EACH OCCURRENCE S _ OCCUR I; CLAIMS MADE AGGREGATE ----5-- DEDUCTIBLE i S RETENTION. S B WORKERS COMPENSATION WC STATU- SH- AND EMPLOYERS'uABIL1TY __ TORY.LIMITS :. .L.ER._ ANY PROPRIETORIPARTNERIEXECUTIVE Y(N E.L.EACH ACCIDENT $ 500,000 _ OFFICERMEMBER EXCLUDED? n - •' -- ----• "'— (MNndatorylnNM) RLWC019737 12/24/2009 12/24/2010 _.E,L.DISEASE-EA EMPLOYEE $ SQO,Qo0 'IFYes,describe under. - ..--------------•-•---....... .. SPECIAL PROVISIONS below E.L.01&EASE•POLICY LIMIT S 500,000 OTHER _ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT.I SPECIAL PROVISIONS - Job: 100 Eatey Avenue, Hya=i.S MA 02601 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OFTH 5 ABOVE DESGR1eED POLICIES SE CANCELLED 19EFORE THE EXPIRATION Town Of Barnotable - - DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN 367 Main Street NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,DUT.FAILURE TO DO SO SHALL Hyannis, MA 02601 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE rV� J LaRocca, Sr/SROGER ACORD 25(2009/01) 1988-2009.ACO.RD CORPORATION. All rights reserved, INS025(200901) The ACORD name and logo,are registered marks of ACORD TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION M _ Parcel l(� /)'N MapApplication# V 1 Health Division Conservation Division Permit# Tax Collector Date Issued 4 Treasurer Application Fee Planning Dept. Permit Fee p 0 Date Definitive Plan Approved by Planning Board f Historic-OKH Preservation/Hyannis Project Street Address A v t Village wan n s Owner / (Ikc K'A125 Address Telephone 'jQ y q T'.g3 L/ Permit Request RR a Irsedeck J Co.. oAA ek1J)VXA d dflVl s,+1�I 0 �l iYle do I� IO 7 �i Square feet: 1 st floor:existing proposed 2nd floor:existing proposed = Total new Zoning District Flood Plain Groundwater Overlay 74 Project Valuation b� 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 .ft (sq ) Number of Baths: Full:existing new Half:existing new Number of Bedrooms: existing new Total Room Count(not including baths):existing new First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use BUILDER INFORMATION Name Telephone Number 3 G7 3 Address s CrOwc /( /l_ License# 0113 Sd Iri rtea J�� ,/1 A 0167 3 Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO grew oA /J 1,12 SIGNATURE kldVa DATE 1 O-07 pppl FOR OFFICIAL USE ONLY P PERMIT NO. DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER J DATE OF INSPECTION: 77 FOUNDATION FRAME CD INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ,r ASSOCIATION PLAN NO. The Commonwealth of Massachusetts Department of Industrial Accidents w Office of Investigations e ' d 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation hasurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LetZibly Name (Business/Organization/Individual): . CyA< Address; alI Cr�owly aj City/State/Zip: Phone:#: Are you an employer? Check the appropriate box: Type of project(required):, . 1.❑ I am a employer with 4. ❑ 1 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. F2!?Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me 'many capacity. employees and have workers' [No workers' comp,insurance comp,insurance. t 9. ❑Building addition required.] ' 5• ❑ Vti'e are a corporation and its 10.7 Electrical repairs or additions officers have exercised their 3.❑ I am a homeowner doing.all work 11.❑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 13:❑Other employees. [No workers' comp,insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy inforination. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. TContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether ornot those entities have employees. If the sub-contractors have employees,they must provide their workers'comp,policynumber. I am an employer that is providing workers'compensation insurance for my employees. Below is.the policy and job site information. Insurance Company Frame: Policy#or Self ins. Lic,#: Expiration Date: lob 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 S 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 maybe forwarded to the Off ce of Investieations of.the DIA.for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and,correct, Signature: UI' //U . Date: t1c'9'617 Phone#: Official use only:..Do not write.in this area, to be completed by city or town offrciaL City or Town: Permit/License# II 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 hiie, 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 =ecelVP.T 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." MM, chapter 152, §25C(6) also states that"every state or.local licensing agency shall Yvithhold 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 beer.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-contiactor(s)na,me(s),address(m)and phone number(s) along with their certificate(s)of insurance. Limited Liability Companies.(LLC) or Limited Liability Partnerships(LLP)with no employees other.than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents, Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials. Please be sure that the affidavit is complete'and printed legibly, The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant, Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current po:acy'information(if necessary)and under"Job Site Address"the applicant should write"all-locations in (city or town)."A copy of the affidavit that has.been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses, A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit, The Office of Investigations would Irke to thank you in advance for your ceoperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number; The Commonwealth ofMusachusttts Department of Industrial Mcidents Office of Investigations f 0a'Washingtcm' Street Boston,MA 02111 Tel. #617-727-4900 ext.406 or 1-977-MASSAFE Fax:9 617-727-7749 Revised 11-22-06 wu�w.mass.gavldia / E 1vyr11 vt 1JaiAJL0LCLLYAVL, IL Regulatory Services snxzvsras Thomas T.Geiler,Director ass. 9`bp,FD ;,,. Building Division Tom.Perry,Building Commissioner . 200 Main Street, Hyannis,MA 02601 www.towA.barnstable.mz.us ice: 508-862-4038 Fax: 508-190-6230 Permit no. Date AFFIDAVIT HOME MUROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovatiori,repair,modernization, conversion, improvement,removal, demolition,or construction of an addition•to any pre-existing owner-occupied building containing at least one but not more than four dwelling units.or to structures which are adjacent to such residence or buz7ding be done by registered contractors,wife certain exceptions, along With other requirements.Type of Work: A c �r i h Ra��.�4 .►h -ex�sAvt2 0�P c/f Estimated Cost �d�U Address of Work: /aU EshI4 A-1 Owner's Name: Date of Application I hereby certify that: Registration is not required for the following reason(s): ❑Work excluded bylaw M'Job Under S1,000 MBuilding not owner-occupied ❑Owner pulling own permit Notice is hereby given that: OWNERS pULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the 97M.C11, qIL Date ' • Contractor Signature Registration No. OR Date Owner's Signature - .. Q:wpfiles.fnmis:horneafndzv . Rev 060606 arm ."T.� a��. °FZHE ram, Town of Barnstable regulatory Services " BAMSTABLE. f Thomas F.Geiler,Director 9`bprf 39. 6. 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 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject property hereby authorize �j,�� C'Alr r- to act on my behalf, in all matters relative to work authorized by this building permit application for: loo 6Ar4 ASP 144ai-4.z (Address of Job) SignatW of CrwneP- Date Print Name Q:FORMS:O W NERP ERM I S S ION pf 324002 ' / I M #95 !!A 324062 �. ✓ / �\ #88 i � r rr � / \ 324063 A\ y a A. 21 a 3 4058 SM yy J V- JK1l h 324064 108 f F � ! FY / NOTE.PARCEL LINES MAY NOT BE ACCURATE. iTe DISCLAIMER:This ma is for planning P P 8 Purposes onty. It parcel lines on this map are only graphic representations of may not be adequate for.lepal boundary determination or '�' �:i �a �`',�� ` t '. �� /"/',�', ;', r 0 10 20 40 F Assessor's tax parcels. They are not true property regulatory interpretation.This ma does not represent an boundaries and do not represent accurate relationships to on-the-ground survey. P, p ,,��YYS 1inchequals30feet physical objects on the map such as building locations. ,A,. ` '` § j� rA' lG ,,. f y,.i H OQ �3 S i 9 : 'TA+R �� X�� Sa�s"I l�lra dxl0 �,yvl�o;s�y�� Posf DoAle fZ►rn�o�s� ��b ol, ¢o ��Se�e r�ra y �Qer� 0