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0231 FIFTH AVENUE (HYANNIS)
as F<r�, C7✓e. - -� � \ . " ' Town of Barnstable Post This CardSo�Thatit isVisible From the Str"eet Approved<Plans Must bemRetamed on Jbb'and'thrs�Card Must be Kept Building �stwace. � 11tt MA&g.' s Un �. Posted tIIF�nal Inspect�onHas Been Made , �, � �. Where a,Certificate.of Occu anc as'Re u�red,such Buildm shall Not be Occu ied pntil a Final Ins ection has been made ;i Permit Permit NO. B-18-655 Applicant Name: SCOTT S SHIELDS Approvals Date Issued: 03/29/2018 Current Use: Structure Permit Type: Building-Deck Expiration Date: 09/29/2018 Foundation: Location: 231 FIFTH AVENUE(HYANNIS),HYANNIS Map/Lot 245.040 Zoning District: RB Sheathing: Owner on Record: 231 FIFTH AVE LLC Contractor`Name:Y' SCOTT S SHIELDS Framing: 1 k "'s .. Address: ATTN:GAIL D BRENNAN � CoritractorLicense CS=065898 2 SALEM, MA 01970Xf Est Project Cost: $21,000.00 Chimney: Description: new covered porch on front of house �z Permit Fee: $ 110.00 � < Insulation: Project Review Req: FRONT PORCH ONLY. MAX SPAN FOR(2)MI0 OUTSIDE Fee Paid'` $ 110.00 BEAM IS 9'0". Date 3/29/2018 Final: t f Plumbing/Gas Rough Plumbing: 1 V ,Building Official Final Plumbing: This permitshaII be deemed abandoned and invalid unless the work authorized 0y this permit is commenced within six rrionths after issuance. *,e .J Rough Gas: All work authorized by this permit shall conform to the approved application1annd�the approved construction documentsfor which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by laws and codes. Final Gas: This permit shall be displayed in a location clearly visible from access street otroad and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. Electrical The Certificate of Occupancy will not be issued until all applicable sign tures by the Buildmg,and Fire Officials are provided on th'is:permit• Service: Minimum of Five Call Inspections Required for All Construction Work = .. 1.Foundation or Footing 4 Rough: x 2.sheathing Inspection 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 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 Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT 1 T!♦E Application Ntmmber............................ .............. . � MASIL ....Other Fee................... Gl��l 01$ �tal Fee Paid..................................................................... TOWN OF BARNSTAB ,Ole J Pemmit Approval by... ........................o :a. 2%�q..>..�...... BUILDING PERMIT e`� �� � APPLICATION .. .`�.�....................rel...............�............................ Section 1 —Owners Information and Project Location Project Address__231 "F t r--f�L A\y a o�L- Village Owners Name C---, L o 3 u\ rn A rl Owners Legal Address b k o r t� 4 e,.t cS e City State ma • = zip 61 q 7a Owners Cell# q — 7 c`/ S�II E-mait C-.A;L Oen r P,re'(-.4<C t Co iv, Section 2—Structural Use Single/Two Family Dwelling ❑ Commercial Structure over 35,000 cubic feet ❑ Commercial Structure under 35,000 cubic feet - Section 3—Type of Permit ❑ New Construction ❑ . Move/Relocate ❑ Accessory Structure ❑ Change of use ❑ Demo/(entire structure) ❑ Finish Basement ❑ Family/Amnesty ❑ Fire Alarm Rebuild M-. Deck Apartment ❑ Sprinkler System [-Addition ❑ Retaining wall ❑ Solar ❑ Renovation ❑ Pool C] Insulation Other—Specify Section 4—Detail Cost of Proposed Construction Square Footage of Proj ect ` G S P,/ Age of Structure G 6115' 5' Dig Safe Number #Of Bedrooms Existing 52 Total#Of Bedrooms (proposed) 110 MPH Wind zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist Design Last updated:11/7r2017 Section 5 -'Work Description Section 6—Project Specifics ❑ Wiring ❑ Oil Tank Storage . ❑ Smoke Detectors ❑ Plumbing ❑ Gas ❑ Fire Suppression ❑.Heating System ❑ Masonry Chimney ❑Addhelocate bedroom Water Supply ❑ Public ❑ Private Sewage Disposal ❑ Municipal ❑ On Site Historic District ❑ Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility:TO 9- OWPe e,,4;A-a S I am using a crane C Yes r No Section 7—Flood Zone Flood Zone Designation ig Within or adj acent to a wetland,coastal bank? Yes an No ❑ Section 8—Zoning Information Zoning District � Proposed Use Lot Area S F nin P q. t. Total Frontage Percentage of Lot Coverage #of Dwelling Units(on site) 1 Setbacks Front Yard Required Proposed Rear Yard Required Proposed Side Yard Required Proposed Has this property had relief from the Zoning Board in the past? ❑ Yes No Last 11nrz017 r ^� 3I- Y Ia �' W � Section 9—Construction Supervisor Name .S -r W t�S Telephone Number �"o T- - 7 3 - Address PA-Ic.t, V 2- City_(',S If- State ULA A . Zip G 7 C 5-� License Number ES GG S F License Type c tto rPs4r,.,,4e2 Expiration Date ? Z, / 2 0 Contractors Email 1 v.iF 6 CP t&,s:►C-,VN r,b ILC m N o w, Cell# Te 7 --23 7 f Cd. I understand my responsibilities under the rates and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and doctanenta#ion rer by 180 CMR and the Town of Barnstable.Attach a copy of your license. Signature _ Date >- 4 i I Section 10—Home Improvement Contractor Name Tr S' D,r,W c In m vtA Pft4 Cis 5 P Telephone Number 576 R Address_- 3 o ar p9,4 4 J— City OS�f er,!t t e State 1 kA e Zip G C s Registration Number ,f7 o d 7 Expiration Date I understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and doctmmentation required by 780 CMR and the Town of Barnstable.Attach a copy of your H.I.C... Signature__,e � - -�/ � - Date / 0'2 f - l F, Section 11 —Home Owners License Exemption Home Owners Name: Telephone Number Cell or Work Number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and docunentat ion required by 780 CMR and the Town of Barnstable. Signa#iire Date APPLICANT SIGNATURE Signature Date - d,,c s i p Print Name J c c, 4 S7 �'h`e 1 (c�S' Telephone Number_ SG k^ 7 - E-mail permit to: in F Q � ��s i Wk n v\ Q e-0 Ve,�, Last uupdated:1117r2017 Section 12—Department Sign-Offs Health Department ❑ Zoning Board(if required) ❑ Historic District ❑ Site Plan Review(if required) ❑ Fire Department ❑ Conservation For commercial work,please take your plans directly to the fire department for approvab Section 13— Owner's Authorization I A c e .�a �-, , as Owner of the subject property hereby authorize , � _(-' P> /c_C to.act on my behalf, in all matters relative to work authorized by this building permit application for: (Agd-ress of j ob) \ -_ 'Q,, Zcs Qnature of Owner date uXL— a 3 a Q-ry Print Name LastWdstea:11/7rz017 Client#:15130 2TRISDE ACORD. CERTIFICATE OF LIABILITY INSURANCE 05/23/2017 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 certficate 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 endorsemenL A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONIACT Dowling 8:O'Neil Insurance Ag RME. PHONE FAX 973 lyannough Rd,PO Box 1990 No pal:508 775-1620 Er mic,NO):5087781218 E-MAIL Hyannis,MA 02601 ADDS° 508 775-1620 R+ )AFI�RDING COVERAGE NAIC# INSURER A:Aa Wabd E�P6C%—6uioanw coagwry 11104 INSURED TRI-S Development Corp. INSURER B: 72 Briar Patch Road INSURER c: Osterville,MA 02655 INSURERD: 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 CONTRACTOR 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. UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LTR TYPE OF INSURANCE SR POLICY NUMBER POLICY EFF POLICY EXP LIMITS GENERAL LIABILITY pEAACCH�OCTCURRENCE $ COMMERCIAL GENERAL LIABILITY PREMS iMarerae S CLAIMS-MADE OCCUR MID EXP(�aM fin) S PERSONAL&ADV INJURY $ GENERAL AGGREGATE $ GEN L AGGREGATE UM1T APPUES PER PRODUCTS-COMPIOPAGG S POLICY PRO LOC s. AUTOMOBILE LIABILITY CD�1H&N®SINGLE LIMB ANYAUTO ac t ALL OWNS) SCHEDULED BODILY INJURY(Per Person) $ AUTOS AUTOS BODILY KIURY(Per accident) $ HIRED AUTOS NON-OWNED AUTOS accident DAMAGE $ UMBRELLAtJAB OCCUR $ EXCESS LIAR cLaMSN�taDE EACH OCCURRENCE $ DED I I RETENTIONS AGGREGATE $ A $ AND EMPLoLIABBITY WCC5005007148 5/01/2017 05/01/201 X WC STATU- OTF4-_ YIN O NBER EXCLUDED?' NIA EL EACH ACCIDENT $500 000 (Mandatory In NH) yyeess, tinder EL DISEASE-EA EMPLOYEE $500 000 DESCRIPTIONOF OPERATIONS bebw E.L.DISEASE-POLICY LIMIT $=.ON DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES(AMsdr ACORD 101,Adddiooa1 Remarks Schedule,if mme space is required) space coverage Is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. Insurance coverage is limited to the terms,conditions,exclusions,other (See Attached Descriptions) CERTIFICATE HOLDER CANCELLATION Town of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCFII BEFORE 200 Main Street THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Hyannis,MA 02601 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIM REPRESENTATIVE 01988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010105) 1 of 2 The ACORD name and logo are registered marks of ACORD 0191207/IY1191206 NS2 The C.onxnv&Wedth of massru:liusetts Dept of Fn&&%WdAcddeais . •1 C,Qngre�s S�ee� T� . ' . Adsttlu,MA B21j4�Z#17 :. . Workers'Compensedon l(nsurrsnce Affirm General Businesses. To SB Fmw WITH THE rmur IIVG ADTHoRrry. AyOcaiat Information Please Print Lembty BusinessA)rganization Name: 7r, S De-e 10 P f%,ek1-( Co P Address: 7 41 c. r 1P-o-ct, 0-c-' City/State/Zip: 0S 4,--v U 1(P M 6aC S 'Phone#. S"6 7.3 -2 a a Are you an employer?Check the appropriate boa: Business Type(required): 1. I am a employer with employees(full and/ 5. ❑Retail or part-time)-* 6. []RestaurantlBarSating Establishment 2.❑ I.am a sole proprietor or partnership and have no 7. MOf ice and/or Salves(incl.real estate, it.,etc.) employees working for me in any opacity. r [No workers'comp.insurance required] S. ❑Nonprofit 3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment their right of exemption per c.152,§1(4),and we have 10.©Mamifiataring no employ='.[No workers'comP'' ] 11.0 Ilealth Care 4.❑ We are a non-profit or c ,staffed by vohtateeis, :with-na employees.jNo worleets'camp.histuaonce*.] • 12.Q Diber 'tlmy that box#1amstAso M obtthcsecbambelovi yingtheirsvor ts':c=R=satibapoticy> on. ++If the corms ofrw=boo exec shemolves,butiiecqT=dmbw odw emp]oyees,a v► Cs'compensatiem P 7 is and an. osgmiza6em shuWA cheeklm#I: I am an employer that is pmvMW workers'coMp ;wahou imumce.formy epees.'Below' Eke paTcy infBnna ux. ' Insurance Company Name: Sa S 5 o C.)h-�� z 'lo ti e �A µ,me- c �h c +C Insurer's Address:T) 3 6an t.o-xv s 12c( • (�d lr3is X I 116 City/StaWzip: W la vt jc i C M p.. . D a-- to 6 � Policy#or Self-ins.Lic.#W Cc- S-6 6 ab )1 Expiration Date: / l 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 ofa STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert ,under thepains andpenaldes of perjury that the Wormadon provided above is true and correct. Signature: Date: Phone#: S_6 .F 3 C a Official use only. Do not write in this area,tabe by. y ertorvn efj CiaL City or Town: Periuwucele# Issuing Authority(drele.one): 1.Board of-Ifealth 2.Ba&*Deomtnent.3.-«t 6M.wn Cleric 4.I; censing°$odd 5.Selecdmen's Office 6.Other Contact Person, •Phone#: www.n- govAHa Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation f+or their employees. Pursuant to this statute,an enploym 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 say two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or do 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 aparI I and who resides therein,or the occupant of the dwelling house of another who employs persons to do mom,construction or repair work on such dwelling house or on the grounds or building apprat at thereto shall not bec mse of such employment be deemed to be an employer." MGL chapter 152,125C(6)also states that"e�ery state or local Ii edusing agencp*O withhold Bra issnanaa or' renewal of a license or permt do operas e a btsiness•er to construct` ulldtnga in the.aommea wealth for nay applicant who has not produced acceptable evnd�ae o�coffipl�ce�vitir:ihie igsaraace coverage reip;ired." :' Additionally,MGL chapter 152,§25C(7)states"Neither the.aoariamweatth nor any of its political subdivisions shall' . eater into any contrail for the performance of public work uattil acceptable evidence of compliance with tie iffiraancc requirements of this chapter have been presented to dre'cont<aoft authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply your insurance company's name,address and phone number along with 4 oertificade of insurance. Limited Liability Companies(L.LC)or Limited Liability Partnerships(LI.P)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,it policy is required:Be advised that this affidavit may be submitted to the Department of Industrial Accidents fbr confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retruaed to the city or tDwn that the application Ir the permit or license is being requested,not the Department of Industrial Accideils. 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. Tire Department has provided a space at the bottom of the affidavit foryou to fill out in thre everu.thie Office of 4r+ gations has to contact you regarding to applicant. Please be'sure to fill is the.pepi0icense miter;oMt.;z.*M be used agi:referee number.hi addition,an applicant that must submit muttigle lrermidlieense appiiitioas is any giveuyeW,need'onlysubmitand affidavit:indicating onrnent' policy inform o (If neqessary A C :-cifthe:afitavk-9ud-has been offiaially'stamped'or a arked:bythe city orto�vn maybe provided to the applicant as proofthis a valid afidavk is oaf&for future'permit l0k licehses..•A'new affidavit must be filled out earth year.Where a:homd owner or*cities is:b�a3ning.a license or permit not related irj airy business or commercial venture('re.a dog license or permit to burn leaves etc.)said person is NOT required to complete thus affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street Boston,MA 02114-2017 Tel.#617-727-4900 ext.7406 or 1-871-MASSAFE Fax#617-727-7749 www.mass.gov/dia Form Revised M-23-1$ y f Commonwealth of Massachusetts i r Division of Professional Licensure ` Board of Building Regulations and Standards i Constr}Ict1'bn Sbpervisor CS-065898 Expires:07/10/2019 SCOTT S SHIELDS ' 72 BRIAR PATCH RD OSTERVILLE MA•02655 s l � Commissioner Cal/ore W--onawyAlkaaaac�u[ae!(s Office of Consumer Affairs Wsinew Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Corporation Rea_ iy� -I. i o before the expiration date. U found return to: offi 1702_7-0: .-- -'. 10/03)2019 ce of Consumer Affairs and Business Regulation TRI-S DEVELOPMEN—T GORP=? ;< 10 Park Plaza-Suite 5170 Boston,MA 02116 SC07T SHIELDS 72 BRIAR PATCH ROAD ,.;', OSTERVILLE,MA 0265 . Undersecretary Not valid without Signature The Commonwealth of Massachusetts Department bflndustrial Accidents II Office of Investigations 600 Washington Street t Boston, MA 02I11 psi www.mass.gGv1dia Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organizatioru'Individual)'.I S �e'v,[ �c�o'Jhv►e�.� (b G Address:_'),)_ jf_�r,,c„f- eA A-el, '(r,v a'A City/State/Zip: _B A,(`vj Alt va/okS G Phone #: 'j 6 73 C Are you an employer?-Check the appropriate box: Type of project(required): L(k.I am a employer with _ 4. I am a general contractor and I 6. ❑New construction and/or part-time).+ have hired the sub-contractors.. einployees'(full 2.❑ I am a sole proprietor-or partner- listed on the attached sheet. 7, Remodeling ship and have no employees These sub-contractors have 8-11�1 Demolition workingfor mein an ca aci employees and have workers' Y P h'• 9. ❑Building addition No workers' comp. insurance comp. insurance.$ 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 I LE] Plbmbin�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' 131-1 Other comp.insurance required.] *Any applicant that checks b6x#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. tContractors 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 Nam e:W G C\% kc.J L t-, \G .•—C S 1.A 513' -Yw,.( C� k/ Policy# or Self-ins. Lic.#;kith C( y q-66`T6 G 7 Iq F~10 l3 Expiration Date: 57- 1 t C f Job Site Address:® !, 'F1IC+L_ 0 f City/State/Zip: lrf� UVP%ihk eof 114ASS Attach a cop),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 a 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. Ldo hereby ce lily under the pacitdpenalties ofperjury that the information provided above is true and correct. Si ature: �aL�� �/ , Date: l'I Phone [..Other only. Do not write in this area, to be completed by city or town official n: Permit/License# thority (circle one). Health 2. Building Department 3. City/Town Cleric 4. Electrical Inspector 5. Plumbing Inspector rson: Phone#: WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Employers Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 (800)876-2765 NCCI NO 40959 POLICY NO. I WCC-500-5007148-2013A PRIOR NO. I WCC5007148012012 ITEM. 1. The Insured: TRI-S Development Corp DBA: Mailing address.. 72 Briar Patch Road FEIN:"-":8313 Osterviile,MA 02655 Legal Entity Type: Corporation Other workplaces not shown above: 2. The policy period is from 05/0112013 to 05/01/2014 12:01 a.m.standard time at the insureds mailing address. 3. A. Workers Compensation Insurance:Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers'Liability Insurance:Part Two of the policy applies to work in each state fisted in item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500.000 each employee C. Other States Insurance: D. This Policy includes these Endorsements and Schedules. SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating Plans. All information required below is subject to verification and change by audit Classifications; Premium Basis Rates Code Estimate Persibo Estimated No. Total Annual Of, Annual Remuneration Remuneration Premium INTRA 404881 INTER SEE CLASS CODE SCHEDU Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: ;w 70270 Type: Office of Consumer Affairs and Business Regulation Expiration a0%412015 Corporation 10 Park Plaza=Suite 5170 Boston,MA 02116 TRI-S DEVELOPMENT,CORP SCOTT SHIELDS 72 BRIAR PATCH ROAD - OSTERVILLE,MA 02655 Undersecretary Ncrt<allid without signature Massachusetts -Department of Public Safety Board of Building Regulations and Standards _ 9 9 Construction Supervisor License: CS-065898 SCOTT S SAIELD$ ;. 72 BRIAR PATCI1 RI OSTERVILLE Mat, Expiration Commissioner 07/10/2015 TME t Town of Barnstable Regulatory Services _. saaxsT"LE, • Mass, g Thomas F.Geiler,Director 16.19. ♦0 �Fo �a Building Division Tom Perry,Building Commissioner, 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-623 0 Property Owner Must Complete and Sign This Section If Using A Builder 6 I, , as Owner of the subject property hereby authorize - - to act on my behalf, in all matters relative to work authorized by this building permit: (A dress 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. Q. #lia ^caner Signature of Applicant P� / Print 14arne Print Name D#/te Q:FORMS:OWNERPEFMISSIONPOOLS 6/2012 �t r Town of Barnst able Regulatory Services BAMSTABL6, - Thomas F.Geiler,Director MASS. �b 16g g 9. •�� Building Division... AIFo A Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied 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) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:forms:homeexempt Inc 1 Town of Barnstable Building, :, ;. 3 • �: ,..: .. .,. .tea. �>� , _..:_ ..._ _V_. ..... .,. Post his, d S :T' ;, �, - s o,,hat t,i V Bible rpm_.the Street A ",Quad Mans Must=be<1t all on J.ob and=this GardaMu t;be'Ke t „ass , y� I t PP �.. p > - , ., . ,osted Until:Final 1 ,w�: .... .- F ns action.Has Been.iVlade. ., _ .. ,. <. <. :y h :. ,. ,. :. .aWher=e,a Certificate=.of:Occu anc 2ss Re usrz-ed� such�.Buald n shalhNot�be:Occu ietl,ontiLai°Fsnal. ns ectson>has�be n:matle.... p Y q s la p P e Permit No: B-17-2809; Applicant Name: kelly keane . Approvals Date issued:_ 08/29/2017 Current Use: Structure Permit Type:. Building-Smoke Detector-Fire Alarm Dection `..Expiration Date: 02/28./2018 Foundation: System Map/Lot 245 040 Zoning District: RB Sheathing: Location: 231 FIFTH AVENUE(HYANNIS),HYANNIS Contractor Name: kelly keane Framing: 1 Owner on Record: 231 FIFTH AVE LLC 2 ontrac C or t License: 1195 Address: ATTN:GAIL D BRENNAN It k ESt oaPrlc.ct Cost: $0.00 Chimne y: Y' SALEM MA 01970 �F ,:PxerrnitFee: $35.00 Insulation: Description: replace exisitng 110vsmoke detectors with low voltage combo smoke Fee Paid:F $35.00 c/o detetors to be monitored by existing alarm system Final Date 8/29/2017 Project Review Req: replace exisitng 110v smoke detectors withlow voltage combo c s, ' RI l J smoke c/o detetors to be monitored by existing alarm system +R tc 1 � - Plumbing/Gas g >� r , Rough Plumbing: Building Official Final Plumbing: This permit,shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within s x months afte,_;ss' ance. A ,,. p Rough Gas: All work authorized by this permit shall conform to the approved application'and't%approved construction documents for which thi's permit has been granted. All construction,alterations and changes of use of any building and structures shall"be in compliance with the local zoning by laws and codes. Final Gas: 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 work until the completion of the same. 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:: k - Service: 1.Foundation or Footing Rough: 2.Sheathing Inspection . 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final' T 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 ":Perso:ns contracting:with unregistered,contractors do.not.have access to.the guaranty:fund'.' (as set forth.in,MGL c142A) :; Building,plans are to be available on:-site Fire Department! Final All Permit Cards are the,property of the APPLICANT ISSUED.RECIPIENT ` , TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Ma Parcel Application # 9—o ^ )v q p BUILDINGDEP� Pp Health Division Date Issued Z5/ Conservation Division AUG 2017 Application Fee Planning Dept. 7"014/N ntF RA R Permit Fee ST,1,3LE Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address ��?, ���^ {sv-e Village 0 OLL v\&S o Owner 12-wJ00k a �Pt�nnCC3w� Address Telephone Permit Request �eA96.� �ao� I l b V swl e_ 14 � "149TQ Colo a S-m h��GD �o �s e M oyi ,reo� 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(sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑ No Detached garage: ❑existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: ❑existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name 41 5 , �:;t,-4 c__ Telephone Number _ L2 D9-12715--?y, /L/ Address �y'7 aI AA&J� - License# / R�10M✓'—_ , AW 6o�(Q 8 Home Improvement Contractor# Email �riJ pLSc,U1�c��C(oe,�d-t�,�s, Cdr✓1 Worker's Compensation #W000OD Mq1 y20 A ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE " DATE ZO q FOR OFFICIAL USE ONLY a APPLICATION # DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. 8 vs as$ a•$ Ira T Ir$ A A ------------- b hEXIST. EXLST. EXIST. EXIST. EX51. EXIST, EXt91. I b I S '.4 N WTEORRY N' u� ILIPKT GtA2utl NEW ROOT TO EE GRQE YIOIDOW Fxsr`ROOF I EXIS 1 EXIST. EXIST. BATH ° EXIST. N9TNL NEW rFFE 6 BEDROOM 3 BEDROOM 2 BEDROOM 1 w cc MTPiL NE W t.b C RRE JOISTSIF NEW CUFIRENfIYLKK010 EXIST. , eKDEbbR 4 SUN ROOM © O b VFNf FAN iO\ rT/ I':.WLIEDEEILW6) vv h REMODELED - - - GARAGE S s Q , ' ) II ✓/yv co I A4P I d tl I I I - j ROUO ATC IIO IW II EXIST. EXIST. I b —NEweee.T REn I I LIVING KITCHEN O� EN RY EX6T. EXIST. O UTIL. I A b EXLSi_ EXIST. EXMT. EXIST. "W, ROOF FRAMING PLAN L�. FIRST FLOOR PLAN NEW ASPHALT ROOF d S1n0I�-�r LEGEND: SNwCIFbd RIDGEVENT S IONATUIEXSTPJG o EXIS INOLKE DETECTORS REVIEWED NEW FA.SUa,SOFFIt,e wn FRIGZE SOMOs IO LLLTON ,cj W "��"' � S�m® L==3 CON TRUCTION TOB RE VE E w'W6 ® NEW ONSTRUCTION DATE E W b°woe W NDDw I ECC2009REbIlUENfl ® iROJ i0 YATCH EXIbT. CLIMATE ZON 5A USE EITHER PRESC I I OR RESCHECK CAL N TABLE 402.1.1 LMI I FENESTF•J.TION SK IbD dV.tSLSPALF WAI. ViKTOR UFACTOR R•vALUE R':YUE R'.W., .. Oaa 0.60 >0 A M IwIJ 10(S FT.OEEP) tOIIJ NOTES: FRONT ELEVATION REART ELEVATION 2.R.YALUEANS R-i CONTINUOUS UOUSI TORS INSULATED MAXIMUMS. 2.OF T MEANS OR CONTINUOUS INSULATED T THE I SHEATHING ON THE INTERIOR OR EXTERIOR OF THE HOME OR R=13 CAVITY INSULATION AT THE INTERIOR OF THE BASEMENT WALL -' 3.REFER TO IECC 2009 CHAPTER 4 FOR ALL INSULATION b ENERGY REQUIREMENTS SCALE: DRAWING NO.: ®Q COTUIT BAY DESIGN. LLC REMODELING FOR: H;e < ' 1/4"=r-0. 43 BREWSTER ROAD .e"eaoN�o.`+•lA '� M .(508) ,4-1 ozsas KLAMAN RESIDENCE o a Al PH.(508 274-1166 DATE FAX(50 )539-9402 231 FIFTH AVE., WEST HYANNISPORT, MA a„� 3/13/2014 v.r ]ad rd Ird rd 1r l . A A 2/101 4 EXIST, EXIT. EXIST. ENST. Ex— EXIST. EXRI. '� '' WRORITY N• 1 MPACTa IX)W NFW ROOT TO OE CIRCLE WwDOW MSTBJQT ( L/\IJ BATL ++ I EXIST. EXIST. EXIST. N9/A LN2w.a FwF BEDROOM 3 BEDROOM 2 BEDROOM 1 a' ar:seoARo INSTALL HEN 2•S CLJMEWL 18FS U D I b EXIST. % SCE glp ACEO.O SUN ROOM a O b DNSOL Fi • VENTF- - b A. -- 1"•'WLIEU4EILWCI — RE DELED EXn1 cEEDARu GARAGE — — II Q - -- ' (2)MNO AJ'-, I� - I sRa�C Ao"E m+a II I - TJ II EXIST. EXIST. I 4wTP«•.uEo I I LIVING KITCHEN o0 OI dif fXfil. FIOST. - UTIL. - J' A � A r—( EXIST. EXIST. EXIST. EXIST. 'M" Yd 11'd ROOF FRAMING PLAN FIRST FLOOR PLAN NFWASPHALTROOF �1� K�--I� r LEGE SHWCIFSARXIGEVENT � �1,,,��1` MOKE DETECTORS REVIEWED - lOA1All:1co raEwFAtcIA EOFFrrA A� C�Q'M I�� Sy`�O O ISTING WALLS FWE2E DOARD910 AATCH ONSTRUCTION TO BE E E EWCONSTRUCTION O BARNSTABL I DEPT. DATE NEWsoINOAvnHoow IECC2109 REST EFFICIENC AILy�'i ® 1R01 TO W1CH E%1ST. TA 6-dCLIMATE O J�W _, � O BLE 4ot.IfA"Ml9M.P_sESGRWX4.VEdNSMhA �T10N. ENE- �TrfWT40N�REeOtREM S) FENESTPATTDN I E](YLXIHT CF0XJ0 WOODFRANEO WAIL FLOVR fuLSEAO:NT WALL BASEAENTSVD CN.'�MLSPAOF WALL ' UfA R UFAGfOR W.'NLUE R.VN F W.:.. RIALUE R.N.UE RvALUE 0]5 BM ]S A ]0 IW13 10(2FT.DEEP) 10113 NOTES: FRONT ELEVATION REART ELEVATION 1.10113 MEANS ES AREANSR 16 CONTINUOUS INSULACTORS TED MAXIMUMS 2.OF T MEANS OR CONTINUOUS INSULATED SHEATHING IO THE INTERIOR OR EXTERIOR OF THE HOME OR R=13 CA':ITY INSULATION AT THE INTERIOR OF THE BASEMENT WALL -- 3.REFER TO IECC 2000 CHAPTER X FOR ALL INSULATION 6 ENERGY REQUIREMENTS BQ®COTUIT BAY DESIGN. LLC REMODELING FOR: " � `�� SCALE: DRAWING NO.: 43 BREWSTER ROADbMa 1/4"=1'-0" MASHPEE,MA. 02649 KLAMAN RESIDENCE M•°°. ° a a . PH.(508 274-1166 a..r DATE: ( ))> 231 FIFTH AVE., WEST HYANNISPORT, MA ` `"�""" Al FAX 508 539.9402 R,,,, 12C,„, 3/13/2014 �I Town of Barnstable Regulatory Services MAS& Richard V.Scali,Director 16111�1�}`�' Building Division. Paul Roma,Building CommiHiOner 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 1. L—I-LLV �i.i�1M.L � ,as Owner of the subject property _ j hereby authorize`T,55�:tnCi f '►`t` I YV-( S��L1�tS , r t� , to act on ray behalf, in all matters relative to work authorized by this building permit application for. 'J (Address of job)' t' , **Pool fences and alarms are the responsibility of the applicant. Pools ate not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner of pplicant tibus Print Name Print e Date Q:FORMS:OWNERPERMS STONYOOLS l Town of Barnstable Regulatory Services ` Richard V. Scab,Director. ►'� Building Division. Paul Roma,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstabie.ma.ns Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, �rrra .iIC �1M(3✓✓� ,as Owner of the subject property hereby authorize`A%661 4Q/� W64MG4a , lvlC_,� to-act on my behalf in all matters relative to work authorized by this building permit application for. (Address of Job) **Pool fences and alarms are the responsibility of the,applicant Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. Signature of Owner Signature of Applicant Print Name Print Name Date QYORM&OWNERPERIMSIONPOOIS Town of Barnstable ' Regulatory Services oOE Richard V.Scali,Director Building Division R&RNSTABLE. + Paul Roma,Building Commissioner MAM 039. & 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied 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) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor (see Appendix Q,Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board 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 this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc 06/20/16 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION O (. ` f Map Parcel �� Application # Health Division Date Issued 7 3� —1 PP Conservation Division Application Fee 41 Planning Dept. Permit Fee �V Date Definitive Plan Approved by Planning Board Historic - OKH _Preservation/Hyannis Project Street Address a3 ( r, 4 4-�A "-v-c-v0J e. Villages P,S' J ,1 yAhm.1S 6-1 "� toy- - Owner a 13 li FA,AJ 67 Address 4 L Telephone S- 3 _ c/.1 3 'S U—0I-A 0.S it- V,^ASS G � Permit Request o v\ u-PC cd4;2 e ® c, A. � �/iC (1/4 64(q 5 Square feet: 1 st floor: existing' proposed 2nd floor: existing proposed Total new s �¢ Zoning District R 73 Flood PlainA , Groundwater Overlay A/U Project Valuatior� z zao Construction IType�� Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Famil # units) o Age of Existing Structure Historic House: ❑Yes No On Old King's;�Oi hway: dYesJ No Basement Type: ❑ Full NJ Crawl ❑Walkout _. ❑ Other Basement Finished Area (sq.ft.) _ Basement Unfinished Area (sq.ft)�15, 6 Number of Baths: Full: existing new Half: existing v new _ I Number of Bedrooms: �- existing —new 1 rs Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel:. �as ❑ 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 ,�cre� � S, s Telephone Number6 '7 "� G� Address P License#� ;c° a2 a j-y— Home Improvement Contractor#If r7 Worker's Compensation #L�JC('s 6 -S-� 7 �' 2vC� �•' ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO SIGNATURE P DATE FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED w MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL - 1 GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. �" ✓ Town of Barnstable *Permit# -a 7�r Ez�fires 6 months rom issue date Regulatory Services Fee * STABLE, • Mass. Richard V.Scali,Director .� 1639- �� o 1v, `, It Building Division ' Paul Roma,Building Commissioner MAR 2 3 2047 200 Main Street,Hyannis,MA 02601 1N h www.town.bamstable.ma.us re✓V l N"0 - ON Office: 508-862-4038 -4Aq- o EXPRESS PERNUT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint Map/parcel Number. D_WS " 0 LA O Property Address 0M r t i T H A V-1 n Ut__ tIV�n n\S 9 o►11T ❑Residential Value of Work® Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address a:!)\ F I YN n LA t; (000 AVe_nU.e , �S,AL,e-c-\ d A Q �R:jo Contractor's Name 6G O i T S)n Telephone Number tl 3 1- 0,9 G-Z Home Improvement Contractor License#(if applicable) 1� d Email: i An n e �e Fi 1q.11 e, Construction Supervisor's License#(if applicable) [ .G 9 .mil 95Workman's Compensation Insurance Check one: ❑ I am a sole proprietor ❑ I am the Homeowner I have Worker's Compensation Insurance Insurance Company Name 14 s v o 4 J-cj J„car rr 4 1 �v r ytn c'e Workman's Comp.Policy# IN c C s S 6 6 - <—o 6 A Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stopping. Going over existing layers of roof) [$Re-side Replacement Windows/doors/sliders.U-Value` (maximum.32)#of windows 4 1 � . #of doors: *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: czlpe �li QAWPFILESTORMS\building permit forms\EXPRESS.doc 01/25/17 Mass. Corporations, external master page Page 1 of 2 {t William Francis Galvin Secretary of • of ' a Corporations Division Business Entity Summary ID Number: 001093123 Request certificate New search Summary for: 231 FIFTH AVE LLC The exact name of the Domestic Limited Liability Company (LLC): 231 FIFTH AVE LLC Entity type: Domestic Limited Liability Company (LLC) Identification Number: 001093123 Date of Organization in Massachusetts: 11-28-2012 Last date certain: The location.or address where the records are maintained (A PO box.is not a valid location or address): Address: 600 LORING AVE. City or town, State, Zip code, SALEM, MA 01970 USA Country: The name and address of the Resident Agent: Name: MICHAEL F. CALLAHAN, ESQ Address: 10 SMITH LANE City or town, State, Zip code, SWAMPSCOTT, MA 01907 USA Country: The name and business address of each Manager: Title Individual name Address MANAGER MARK KLAMAN 600 LORING AVE. SALEM, MA 01970 USA In addition to the manager(s), the name and business address of the person(s) authorized to execute documents to be filed with the Corporations Division: Title Individual name Address The name and business address of the person(s) authorized to execute, acknowledge,.deliver, and record any recordable instrument purporting to affect an interest in real property: Title Individual name Address REAL PROPERTY MARK KLAMAN 600 LORING AVE. SALEM, MA 01970 USA http://corp,sec.state.ma.us/CorpWeb/CorpSearch/CorpSummary.aspx?FEIN=001093123&... 3/23/2017 Mass. Corporations, external master page Page 2 of 2 ❑ ❑Confidential ❑Merger ❑ Consent Data Allowed Manufacturing View filings for this business entity: ALL FILINGS Annual Report Annual Report - Professional Articles of Entity Conversion Certificate of Amendment �z View filings Comments or notes associated with this business entity: V New search http://corp.sec.state.ma.us/CorpWeb/CorpSearch/CorpSummary.aspx?FEIN=001093123&... 3/23/2017 The Commmmeakh ofMammhm & Depwhaeut of rad vbid AcQdamS. WJ 600 Was or j, reet Bastm,MA 02HI kcTvmmOSmg P1d1a Wa-kets' C am•Insurzmce Affidavit M�lC,mh AchmsMechidausNhumbers Applicant Warmatan Please Prim F Iv -I`tm= 16- C iJ--vef.oloaarr/4 Addre= 17 c"C F r[r r 69-4,4 /Lo Ltd ' C S� C>S4�-e-rvrCle !�14o�t,5-- Thom ��dF-73 � ra Ar you an emplo, er?:Qteckthe appropriate b� Type of project(reed): L I mn a employes with 4 ❑I am a general coafractaar and I 6. New❑ employees(fall andfor part#ime)-* �e hired Ifie solr-coatractam 2_El aaa a sale proapzietaf arpartner- IL d aathe attached shut I- ❑RPM doing. �ese sub-caafractars have ship and have no employees $ ❑Demalifiart wa long farmer in any may- employees and have wad=' [No wad=&OOmP.inset= a Comp.imca ce 1rcqxkeA B�ual�a&tifiou -] 5. 0 We=e;a cmpozafim=d its 10-0 Etecfdc d repairs or add oas 3_❑ I am.a haomwvnw doing all wmk oTleers h=deed f mir 11-0 Fh=bsagregaim or additions ' myse1f[No • might of lirf{E. ammnm required-]T �. �§I{ eer we ba�ue a�o L. Roof repaim employem(No waADEzs' 13_/�'f�tberYl.cwne.3'!•1Me.sS 'Any opus-ta w cbmubos ff1 mast slsa fiIla�tte s r6mbelowshns�&eir Waajcme compe mf=porkyfafvamsaoa l -basabmft this r syamdaig allvrokmaambie m stsmkmu$naw> s fcoatr 8 ca�ecicti¢zt�ooc wed sddiliffiaYseersLoR�gtieea�meofuzesobcao �ds�fe�rhethaaraoct ee shgee Ia the base earpivs�rs,cheyams<gmvidtitaea 'aaap.parity member I am evipl sr that isgrmridirrg tvar&ers'coamger ort iirsrr rases fnr my eaxg gee $eIvav is fiteprrticy aad jQ�i szte Fxfarraatrva. , . Tnci,ranc�COzalpaayl"�azue: 'V ti SS 6 G A kc ►1a lbc/Gf s y�S P A�-a o P Pflficg 44,c r Self€Lie.;g:W Cc s SO G - S-o a 7 i q —20 f 4; l pigafiaaI?ate: o 1 r 7 rob ddn= 2 3 s F, ;4i A-,e,4 e . 1-1 ill tf cityrsr : Attach a-copy of the warkere compeasatieapolicy dedaration page(ah'DWiug the policy=nber and expiration date). Fair to seame Coverage as requiredunder Swim 25A o€M-GL L f5 cm lead to the imtpossfioa 4f criminal penalties of a fine up to$1,54a QU an&or oii,:g&irimprisozu� ss we11 asrivfl penalties n the fans of a STOP WORK 01=and a frm,e of up#za F3St a day a the sriolafor_ Be whised'tiaaf a copy o€fis sbhment=aybe£rwarded to t1ie Office of lmvestipations o€the DIA for msu umm coverage verifficadicm- Ida F rainy axtrdsr f&s yams mtdgsraa s FeJWF fhattfis imfarmatiauprm.'tded abm c is true and cmrect Date- Z, 5LI;> Ph==A- S d � " �j � d��2 G oZ Op id we a* Do ma write im fiih sm,to be misp$eta by city ar'tolm Voldat CRy or Ta ww Pernhfficeme;g lisaing y(cacleone): L B02rd of H9211ffi 1 BwWmg Dgmtnffit 3.CAY fPolrn.Camk 4.Electrical r.S.Phmbing bVector . C.Men C'anfact Person: Phase#: 6 IF iI: ..I1I.�... ii■�' w■:.■.� �•■•1^ •' ^UI/to•:iR Nt :If all Bel it" t Vital■ ••�" •■. ...■1 .. i. A Irl■/Il' _■. �♦.♦ ♦ •- Il■�. -•� ■�R■. 11 i■ � • :n.■r� .I.■� :1. 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'III" •✓■. t ■. wl • w 1• Y.II/1.�■ ■1 ■r.1/.r:■ .• It wl U tr•'1 ■/ .- // •• •�/ 1• ■■ t■••. •■ • ■t- ..a■.•1 It. ._ .��t • LI w a.. Iv_n_ n a• o. ■ .G■■: 1 ■. B' n Int/t - /.+m IA n ►�. {' Gt■.• 1 nIt .' ill�• •n _t t�/ ■.Il - ■••1�'. a/ MIa /a!l ■.r_/■{ ■■• ►�!■ ■I / ■■■1 t• :■�■ l• .Il• •a YIt�. • r.U t■ w •�!111■1 - ••• rue - . e:!w 1 n a rn �■ w ■ ■.�a.■t � �■m .a a rnnu :,r a it■. a" � G■ • . ■•:n u1 ••■■ ■ .•- n n:n. ••t n _l•.n r. B •n ..•/:a .nm .n■ t•. a -a. a_ • .n •a:�a a). • - - .■ ■■ ■wYlrn ■• •J• •A r 1 on- :I ■at:!t : sat -.., l- �.t.n- .1918 r-_ ■Itm/ r ._■r�.r._r n r a ■��■ti �i ■. a ■ ' :.�■■ ■ ■ a I n• 1.±. C - . I 'll as ' 9. s ; ; ' ti. ' • Town of Barnstable ' .� Regulatory Services r r r r M"a t Richard V.Scali,Director - qua Building Division. Paul Roma,Bmlding Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.ns Office: 509-862-4038 Fax: 508-790-6230 - Property Owner Must r Complete and Sign This Section If Using A Builder -,as owner of the subject property hereby authorize C-c.TT V �C 1\ �.�S to act on my behalf, in all matters relative to work authorized by this building permit application for. a�1 Ftr— =n A ca (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. Sigriatute f Owner' Signature of Applicant Pant Name Print Name Date�� QFORMS:OWNERPERMISSIONPOOT S Town of Barnstable Regulatory Services Richard V.Scab,Director Building Division HAsNsresca. ` Paul Roma,Building Commissioner KAM e39. �� 200 Main Street, Hyannis,MA 02601 p � www.town.barnstable.ma.ns Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": . - name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied 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 ?erson(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 requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shalFact 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 this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit fonns\EXPRESS.doc 06/20/16 VJae tpomvr�aararaeacGfzall�/vca4��accoeu� Office of Consumer Affairs&Business Regulation License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration:..;:'170270 Type: Office of Consumer Affairs and Business Regulation Expiration:_=1'6 2017 Corporation 10 Park Plaza-Suite 5170 = == Boston,MA 02116 TRI-S DEVELOPMENT---CORP=v= SCOTT SHIELDS - -_ c 72 BRIAR PATCH ROAD OSTERVILLE,MA 02655 y` Undersecretary Not 4lid without signature lLOZ/OL/LO Jauo►ssiwwoD uoijelidx3 XK TYHA2IB.LSO tr &W 1131Vd NMI[ZL r(nzm S L LOaS �- \7:3; �. ytr �.►.1�5, 86899045-3 :3su8311 spjepue}S pue suo11eln6aN Suiplinl3 to pjeog s}}asnyaessewl f4aos oilgnd 101uau4jedaQ- WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY INFORMATION PAGE Associated Employers Insurance Company 54 Third Avenue, Burlington, Massachusetts 01803-0970 (800)876-2765 NCCI NO 40959 POLICY NO. WCC-500-5007148-2016A PRIOR NO. I WCC-500-5007148-2015A ITEM 1. The Insured: TRI-S Development Corp DBA: Mailing address: 72 Briar Patch Road FEIN:*=***8313 Osterville,MA 02655 Legal Entity Type: Corporation Other workplaces not shown above: 2. The policy period is from 05/01/2016 to 05/01/2017 12:01 a.m.standard time at the insured's mailing address. 3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers'Liability Insurance:Part Two of the policy applies to work in each state listed in item 3.A. The limits of liability under Part Two are: Bodily Injury by Accident $ 500,000 each accident Bodily Injury by Disease $ 500,000 policy limit Bodily Injury by Disease $ 500,000 each employee C. Other States Insurance: Coverage Replaced by Endorsement WC 20 03 06 B D. This Policy includes these Endorsements and Schedules: SEE SCHEDULE 4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating Plans. All information required below is subject to verification and change by audit. Classifications Premium Basis Rates Code Estimated Per$100 Estimated No. Total Annual Of Annual Remuneration Remuneration Premium INTEA 404881 INTER SEE CLASS CODE SCHEDULE Minimum Premium $317 Total Estimated Annual Premium $526 GOV GOV Deposit Premium $536 STATE CLASS MA 5606 State Assessments/Surcharges $173.00 x 5.7500% $10 This policy,including all endorsements,is hereby countersigned by 03/11/2016 Authorized Signature Date Service Office: Miller McCartin dba Dowling&O'Neil Ins Agcy 54 Third Avenue 9731yannough Road Burlington MA 01803 Hyannis,MA 02601 WC 00 00 01 A(7-11) Includes copyrighted material of the National Council on Compensation Insurance, used with its permission. 1�r - r Since 1955 GACO r Insulation Certificate 's " Date installation completedi��� �: Building address—off i—c—, :e, City/State/Zip; G��� Gi\/ �`Y' �/ 16 Application Contractor(company name) Address N �- City/State/Zip Phone Areas Insulated S Exterior stud.wall Average thickness R-Value Ceiling Average thickness R-Value Roof deck Average thickness R-Value Crawl space/basement Average thickness /�, - R-Value Additional areas insulated ' I(print name-) � ;� as an'independent contractor,certify that the GacoWestern insulation n. installed on this project'was_applied in accordance with the GacoWestern recommendations and specifications as stated on the product data sheeand .tie GacoWestern 7.pplicat{ i�o pecifications in the amount as indicated on this certification. -- (signed) Date13 ? ' V GacoWestein Aged R-Value Chart t r Dimensional Lumber 1" P' 3- 4" 5„ 6" ;1„ N 8" 9" 3:5„ 5 5" 125" GacoGreen 4.2 `8;f' 12 16 20 24 28 32;:r 36 14 =ZZ Z9 GacdireStop 3.7 '7 11 15 19 22 26 30 33 13 `20 21 183M 6.4 13 ` 20 27 33 40 47. 53 60 Z3 `31 48 184'- 6.1 13 20 27 34 40 47 54 60 24 31 49 193 6.2 1 13 -20. 27 34 41 47 54 61 24 37 49 ,. 'Based inlndialmeasuredK-values: I 1 GacoWalIFoam SPRAY POLYURETHANE FOAM INSULATION www.gacowalfoam.com 'I 800.456.4226 I q PROUT DATA - 1 Walffoam System 183Mter: Gaco Western WallFoam 183M is an HFC-blown(zero ozone-depleting)liquid spray system that cures to a medium-density rigid polyurethane insulation material.Gaco WallFoam 183M contains polyois derived from naturally renewable oils,post-consumer recycled plastics,and pre-consumer recycled materials.GaEO WallFoam 183M does not contain CFCs, HCFC's or other gases harmful to the environment.This system can be sprayed on clean,dry substrates down to 35°F(2°C).Gaco WallFoam 183M is a class I fire rated foam that meets the requirements of ICC-ES A1377 Acceptance Criteria for Foam Plastic Insulation.Gaco WallFoam183M meets the requirements of A1377 Appendix X for use in attic and crawl spaces without an additional ignition barrier. INFORMATION To ensuoptimum performance, of recommended with the maximum not to per pass. ir typical equipmentf f Gaco foam PROPERTY TEST TEMPERATURE ASTN TEST UNIT VALUE Nominal Density(Sprayed Iq Place) s 11°F(15"OD 1622=03 Ibs/ft' r4 1 S 2 2 1 R Value'See Note Below °' 15°F(23.9°() `' + (518 l�h ftz °F/Btu a_x ' h $? t35°F/Btu R233ay _ _. w. �t _>. :. Compressive Strength(Parallel to Rise) 71°F(25°(� j� A{D 1621 04a psi P 3Z " ; y j' Tensile Strength. 11°F(25°t) p __.. _.- x t, r..,.... ,..-,. N r_ .s. D 16Z3 ._ _SI,. _. i 64 ... € r� Water Absorption . .T` 1]°F(��()� _ ; s 045{ tx s Water Vapor Transmission % 77°F E 96 05 g perm-in 112 ; Di mensionai Stability(1 Days) t w `y 158°F(70"O/95%RH' ;' D 2126-99 a z r%linear change L 6% W 5% T=3% Recommended Servue Temperature Range 11°F(15w17 r. k,'i °F/k $ ;40°F to 200tE 40°C to 93°O closed(ell[ontent 3 1T°F(25°f) `.,,; .y, ry ��yD 6226 05 Au Permeance @ 15Pa(Inhltrahon/Exfiltration) 77°F 283 000/0 000;(@ 1 thukness) ,., i � �t M N01E1etaANn�ont �iatllcfede�IT1G{{Ilkat46D 1t�Rvof ;. IiDA9ewBtlllcte�aBagedsaes�a75'f ��m�nteiah�fetklretotoR�hrcanreRdt•Insu�hataldrelfele�i�4beE(C: � � - � � �:..Y. x�,�: I f and SYSTEM THICKNESS FLAME SPREAD INDEX SMOKE DEVELOPED INDEX WaItF0am163M; :a -4 102'im) L'10 y 40Q 34 '11 1' Appendix LOCATION FOAM THICKNESS Y m ceilinUp to I I PROPERTIESComponent f ff f ff r ff f blowing PROPERTY TEST TEMPERATURE ASTM TEST UNIT VALUE Viscosity A component: $ 77°F(25?t) ` D 2196 68 ,t �} cps,` 180*20 r rt Viscosity `B Component �t r; r 750±50 a 66 avity' A component r 11 F(25 E)S ecifii D 1638-70 S G S ecitu Gravlt B coin onent p VY p. ti Y F _ 4 120- t Weight/Gallon A Component Y -17°F(25°() Weight/Gallon B,Component f q 10 0 Mixing Ratio component By € Stability When Stored at 50 F W 70 F F }fi y §* . Months A Component.l year 1 (10°(:toll°q fi_ z ,.' �"" s '.«..y._t,_ _. ._,_ ,�B (omponent:6months: EQUIPMENT SETTINGS "tl SETTIN6 VALUE" CHARACTERISTIC VALUE Pre Heat Iso(A) T7115'F 130°F(461°C 54 4°O t (ream Time ` �; 0 1 sec` x PreFHeat Poly(B) #�115°F 130°F(461°(, 544°C) RiseTime «° ;ffif3 5sec Hose Heat r 4"° 115°F130°F(461"( {54 4°q st Tack Free Tlme ' + 3 5sec .x y �y Recommended Spiay Pressutek M 800 1000 psi(dynamic) hours ? The Information herein is belieired to be re0able but unlmewn dsla mag be present ALL WARRANTIES OF ANY MIND,EXPRESSED OR IMPUED,INCLUDING WARRANTIES OF FITNESS FOR A PARTICULAR PURPOSE ANDTHAT 6000S ARE OF MERCHANTABLE QUALIFY,ARE SPECIFICALLY DISCLAIMED.See Gain Western forinfomu0on concerning its Nmibed warranty and its aealiabiHtg. � e:.» �'-'..#y,�`�"'�a�,�2 ,• ..�y:'d« ����' � �+'r1.*�.:5- Z.F'`'4 ��� •mx� g ,pe�9. .sr,�— �? - 7 OV GACO WESTERN Y ti OOtYVV I, I y- a � ENEflGY STAfl _t.� f W�?P^mh^a^udl�Lrinamv W.,14l—NaStm�o..Nbm600d.cool cou - r^y' PARTNER �' WewmAupac d.6 lmm•.i"su(oanm.MEMBE . Toll-Free:877-699-422.6 www.gaco.com ProducteGWFOSI Bv12 1 3 3 Commonwealth of Massachusetts Sheet-Metal Permit Map Parcel oqo X-PRESS PERMIT _ � Q Date: MAR 2 5 2013 d� Permit# �: U k3 Estimated Job Cost: $ Zd4 ao Permit Fee:$ 163 S Plans Submitted: YES NO TOWN OF BARNiUwed: YES NO Business License# 4 Applicant License# L Business Information: Property Owner/Job Location Information: Name: Name: �.AM" Street: 'e��,&e C 5,17 Street: a 3 I off S t City/T City/Town: kc2 4ze t'IA[oS k1— Telephone: <0 S— Telephone: Photo I.D. required/Copy of Photo I.D. attached: YES NO stalpitial J-1 7.1- estricted license J-2./M-2-restricted to dwe s 3-stories or less and commercial up to 10,000 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.Z over 10,000 sq. ft. Number of Stories: Sheet metal work to be completed: New Work: Renovation: / HVAC Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents Air Balancing Provide detailed description of work to be done: t r, y t NSURANCE COVERAGE: have a current liabill insurance policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Yes�No ❑ f you have checked YM, indicateXttype of coverage by checking the appropriate box below: k liability insurance policy Other type of indemnity ❑ Bond ❑ DWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the Jlassachusetts General Laws,and that my signature on this permit application waives this requirement Check One Only Owner ❑ Agent ❑ Signature of Owner or Owner's Agent 3y checking this box[],I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and iccurate to the best of my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be n compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws. Duct inspection required prior to insulation installation: YES NO Progress Inspections Date Comments Final Inspection Date Comments ;/e License: y Master itle ❑ Master-Restricted ity/Town , ❑Joumeyperson Signature of Licensee ermit# ❑Joumeyperson-Restricted License Number. ee$ ❑ Check at www.mass.gov/dal ispector'Signature of Permit Approval T ie Commonvealth of Massachusetts Department of£ndustdal A cidents Office of Invesfigatiorss- '600 Washington Street ' Boston,MA 02111 www.mass gov/dia ' Workers' Compensation InsurAnce Affidavit: B'udders/Contractors/Electridans/Plumbers Applicant Information Please Print Le�l� Name(Bzsh=ss/0rganizati=1dividn4 City/&&&Zip: Cod( 0 7WS' Phone.# .A.re you an employer?Check the appropriate bow Type of pi-oject(required):• 1.❑ I am a employer with -4• ❑ I am a general cnntrartor and j employees (�xiIl and/or part time*. * have hired the sub=conaciors 6. ❑New oonstrnction 201 am a'sole pioprietor or partner- listed on the-attached sheet 7. $emode}ing. ship and have no employees These sub-con ractors.bavc 8. ❑Demolition working for me in:any capacity. employees and have workers' c Msuranoe.$, 9' El Bmi ding addition [No workers' cow.incrtran�e amp.. • .. ' regtrred.] 5. F�-We are a corporation and' 10.[]Electrical repairs or additions officers have��ised ibex leg 3.�] I am a homeowner doing aIl•work 11,E P r airs or additions E el£ [No workers' c®p, right of exeurpdon per MGL 12❑Roof repairs insmmme,regomed.]t c. 152, §1(4), and we have no employees. [No workers' 13 = WU+�-� comp.insurance required•) *Any applicaant that checks box#1 nmst also fill out Em section below showing this wofl=,compensation policy information• t Homeowners who submit this affidavit mdicaiing they are dig all work and then Imr ontside conhactxs most submit a new affidavit;ndicaimg such. $lontractrrts flLd check this box mast affarhed an addi�ti�onal sheet showing the name of thb sub-contractacs and state whether arnot those e�ties have employees. If the Sub-cuat�hav �{ e Cmpiny—,J mnstpruvide al zir work='conIp,policy Cr.IIIImb I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site , information. Name: �, •- .Iusazance Company Policy#ar Self-ins.Lic.# l J .�() �ri�,�' t FonDate: lob Site Address: -3/ 1 l:t�Te6�'7 az 4 C�y/Si�e/ZiP: Attach a copy of the workers' ca�ensation policy.declarafion sha the policy number an P�( �� P cy d eapu•aixon date). Fame to.secme coverage as required under Section 25A ofMCI c. 152 can lead to the inpositim of anal penalties of-a foae up to$1,500.00 and/or one-year m msa�ent,as wen as'civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the vioL�ton Be advised that a copy of this statement may be forwarded to the Office of Investi ons o DLVw insurance coverage vediicatinn. I do hereby th -and penalties of pedwy that the information provided above is true and correct, Side: Date Phone — a Offrr:al use only. Do not write in this area,to be campieted by rnY or fawn ajj7rin] City or Town: PermitUcense# Issue Anthority(circle one): .1.Board of Health 2.Bmlding Department 3.My/Town Clerk 4.Electrical Inspector 5.Phrinbing_Inspector 6.Other Corfzct Person: Phone#:. �tHE Torten of Barnstable t t Regulatory Services MASS �* Thomas F.Geiler,Director l6;q. t� 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 Pro e Y Owner Must Pp Complete . p and Sign This Section . If Using A.Builder I, i 614 ,as (der of the subject property hereby authorize &�6 �,, to act on my e b � in all matters relative to work authorized by this building permit (Address of Job) **Pool fences and alarms are the responsibility of the applicant. .Pools are not to be filled-before fence is installed and pools are not to be Utilized. until all final inspections are performed and accepted. S S' tore of pphcant Print Name Print Name D ale Q:FORMS:OWNERPERMISSIONPOOLS I • fr �tHE Town of Barnstable. Regulatory Services • inaxsrwsl,E, • Thomas F.Geiler,Director r yes. 1639. Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.b arnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied 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) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. ' HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109,1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,'that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Regulations fnr Licensing Construction Supervisors,Section 2.15).This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:for ms:homeexempt �y COMMONWEALTH OF MASSACHUSETTS SHEET METAL WORKERS AS A MASTER-UNRCESTRiCTED ISSUES THE ABOVE LICENSE TO: CRAIG R BORDEN m - "PO BOX 1577 HARWICH MA 02645-6577� 1833 11/28/13 71596 Fold,Then Detach Along All Perforations , i i i I I { TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map p`"/S�_ — Parcel C)C14 Application # . : O6 Health Division Date Issued J Conservation Division Application Fee Planning Dept. Permit Fee /7 Date Definitive Plan Approved by Planning Board P� Historic - OKH _Preservation / Hyannis F Project Street Address �'3 r. X Village U'0—� - Owner e- G Address Telephone Permit Request n" r 4 _WA),O AYV 4)A I AAl4d A)d4l)f , !24-�, mvk 1) V-4A6 AhFa,5�CAk, , brl,4 L lDC� � Square feet: 1 st floor: existing/ proposed a 2nd floor: existing C-5 proposed Total new Zoning District A R 3 Flood Plain e Groundwater Overlay P Project Valuation v G Construction Type Lot Size Grandfathered: V Yes No If yes, attach SQQP doeUmtion. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King s: 'i;hway: 0Yes ] No Basement Type: ❑ Full q Crawl ❑Walkout ❑ Other ' Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) -- Number of Baths: Full: existing new e9 Half: existing new Number of Bedrooms: C _ existing —new Total Room Count (not including baths): existing new d First Floor Room Count Heat Type and Fuel: Gas ❑ Oil ❑ Electric ❑ Other Central Air: ❑Yes CNo 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) sir. Name-Tyr;.. s t �,�r��;'�c � o�c f',� f -� �� elephone Number Address f3`ec, r P?� cc, 4Q License # 6, J_ Y G�S4c c i, o //-e Pt4/+ - 03 S— — Home Improvement Contractor# 1,7G 7 Worker's Compensation #IAJ[� ��D ! 2 v i ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO t1 F SIGNATURE /� DATE 0ee �- _ r FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER' DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. - -• �- 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/Oro ni7ation/Individual):Tt'J P C- I!! P im,,t ON P, Ec-c 4 f � �� (C Address:-7 City/State/Zip: ()-5kc:i P I`/l P {AA- 0 G�'�"" Phone#: ��� � - ,� 3 7- Are you an employer?Check the appropriate box:1.MI am a employer with 1 _ 4. ❑ I am a general contractor and I Type of project(required); 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. 0 Remodeling shipand have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. employees and have workers' coin insurance. 9. ❑Building addition [No workers' comp.insurance comp. required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doingall work officers have exercised their 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 employees. [No workers' 13.0 Other comp.insurance required.] *Any applicant that checks box 01 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. 3 Insurance Company Name:A S 5 ' jr f iy+R �1•,'1 p (© Cl $ $ v tf to-c l e' of Policy#or Self ins.Lie.#:W C.0 , ca(s( j q a jG' j Expiration Date: S— - Job Site Address: City/State/Zip: W eS`+ J..I/ 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. Si':a ereby cer fy under the pains and penalties ofperjury that the information provided above is true and correct ore: �- /�� ='�i Date: Phone#:" S~U a—�L 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 Con Person: Phone#: . _ I Client#: 15130 2TRISDE ACORD,. CERTIFICATE OF LIABILITY INSURANCE DATE o7/(MMIDO(MM/DD/YYYY) 2 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 WANED,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: Dowling&O'Neil PHONE 508 775-1620 FAX 5087781218 AIC,No,Et): A/C, No Insurance Agency E-MAIL ADDRESS: 9731yannough Rd., PO Box 1990 INSURER(S)AFFORDING COVERAGE NAIC# Hyannis,MA 02601 INSURER A:Landmark American Insurance Co INSURED INSURER B:Associated Employers Insurance TRI-S Development Corp. INSURER C 72 Briar Patch Road INSURER D: Osterville,MA 02655 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 CONTRACTOR 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MM/DD MM/DD/YY A GENERAL LIABILITY LBA15641500 4/02/2012 04/02/2013 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISETo RENTED nce $1 OO,000 CLAIMS-MADE I I OCCUR MED EXP(Any one person) $5,000 X BI/PDDed:500 PERSONAL&ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 POLICY PRO-- LOC $ JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS' Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ B WORKERS COMPENSATION WCC5007148012012 5/01/2012 05/01/201 X wCYrLTuQjS ER" AND EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N E.L.EACH ACCIDENT $500 OOO OFFICER/MEMBER EXCLUDED? � N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) . Insurance coverage is limited to the terms,conditions,exclusions,other limitations and endorsements. Nothing contained in the certificate of insurance shall be deemed to have altered,waived,or extended the coverage provided by the policy provisions. CERTIFICATE HOLDER CANCELLATION Town of Barnstable SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 200 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Hyannis,MA 02601 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION.All rights reserved. ACORD 25(2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD #S98326/M98325 LS1 'ME T Town of Barnstable Regulatory Services + B"NSTABLE. y NAM g, Thomas F. Geiler,Director �A t639. �e r�Nay" 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 h A , as Owner of the subject property hereby authorize �'G� to act on my behalf, in all matters relative to work authorized by this building permit. u� (Adess 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. ZZ d ignature of ner Signature of dpplicant C4,� Print Name Print Name Date QTORMS:OWNERPERMISSIONPOOLS 6/2012 z� Town of Barnstable Teti . Regulatory Services (; lARNSTASLE, ; Thomas F.Geiler,Director 9 MASS. 0.19. a Building Division tFD MA'I Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 62601 www.town.barnstable.-ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: / city/town state zip code The current ex;mption 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) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said"procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION. The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1 -Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor,(see Appendix Q, Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is ultimately responsible. To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application, that the homeowner certify that he/she understands the responsibilities of a.Supervisor. On the last page of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in your community. Q:forrns:homeexempt Office ot�ousumerairs mess egn a on License or registration valid for individul use only HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: Registration: 170270 Type: Office of Consumer Affairs and Business Regulation Expiration: 10/4/2013 Corporation 10 Park Plaza-Suite 5170 Boston,UA 02116 kT `EIXF-LbPMEN- CORD SCOT? SHIELDS..`:, —: _? 72 BRIAR PATCH ROAD_ Y � OSTERVILLE,MAD = Lnderseci•etary Not valid without signature Massachusetts- Department of Public Safer. Board of Buildin-« Red-ulations and Standards Construction Supervisor License License: CS 65898 SCOTT S SHIELDS 72 BRIAR PATCH RD OSTERVILLE, MA 02655 �- - Expiration: 7/10/2013 r'ununissioner Tr#: 21168 IJ v I� Town of Barnstable *Permit# Expires 6 months from issue date X-PRESS PERMIT Regulatory Services Fee��.S�; Thomas F.Geiler,Director n ,SUN - 5 2007 Building Division TOWN OFBARNMIXE Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-8624038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint lap/parcel Number___2 1A J roperty Addres433AP1 144 Residential Value of Work / Minimum fee of$25.00 for work under$6000.00 wner's Name&Address + A ? ontractor's Name_ /� (Z?,y-� Telephone Number Me Improvement Contractor License#(if applicable) 11 instruction Supervisor's License#(if applicable) ]Workman's Compensation Insurance Check e: I am a sole proprietor ❑ I am the Homeowner ❑ I have Worker's Compensation Insurance surance Company Name orkman's Comp.Policy# )py of Insurance Compliance Certificate must be on file. rmit Request(check box) Re-roof(stripping old shingles) All construction debris will be taken to f 0 4.t/,P ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows/doors/sliders. U-Value (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. NATURE: orms:expmtrg ise061306 ✓fte V��y��Z��j^j✓,i2��'/ea� a�i/['i��uo�N��^��c6e�4 f Building Re and Standards Board o g Regulations g 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 Registratlon 1.11859 One Ashburton Place Rm 1301 '-Expiration 2/4/2009 Tr# 126859 Boston,Ma.02108 � 'f Type DBA` MICHAEL RENZh`'CONSTRUCTIO'N MICHAEL RENZI 387 PHINNEY'S LN CENTERVILLE,MA 02632 Administrator Not valid wi ho signature f C✓ Inc k urritnurlPVVU&IU Vf 1rluaaUcrs"artW Department of Industrial Accidents Office.of Investigations 600 Washington Street Boston,MA 02111 '�M S�•' www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers applicant Information Please Print Legibly Jame (Business/Organization/Individual): /,,t k tti t10-.,,-j?k Tic Ow- kddress: 3� 1 N,,t - �ity/State/Zip: C Q.,Ac ,f Vl Phone#: 5-.6 --7 ,re you an employer? Check the appropriate bob:. Type of project(required): ❑ I am a employer with 4. I am a general contractor and I 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors ❑ I am a sole proprietor or partner- listed on the attached sheet t ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions ❑ I 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' 13.0 O her ,6,@ V R a o�F comp. insurance required.] ny applicant that checks box#I must also fill out the section below showing their workers'compensation policy information: '• omeowneis who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such mtractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information. m ann employer that is providing workers'compensation insurance for my employees. Below is the policy and job site 'ormation. ;urance Company Name: licy#or Self-ins.Lic. #: Expiration Date: Site Address: City/State/Zip: tack a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). ilure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a e up to$1,500,.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORD ORDER and a fine up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of iestigations of the DIA for insurance coverage verification. 'o hereby certify under the pains andpenalties ofperjury that the information provided above is true and correct: mature: Dater J a �. one#: '-d - Q G Official use only. Do not write in this area,to be completed by city.or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: WE►° Town of Barnstable Regulatory Services sa MAMSS i a Thomas F.Geiler,Director 9� a639. `0� '0�E°► Building Division Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I, I C L-,(r O k ► , as Owner of the subject property hereby authorize_ A 1 �t to act on my behalf, in all matters relative to work authorized by this building permit application for: (Address of Job) Signature of Owner Date Print Name Q:FORM&OWNERPERIMSION 05/18/2007 15:21 508-790-0249 GULDI•-1AN N ASSOC. PAGE 01/01 CSR A8 DATE(MMIDDIYYYY) �4COfi?D, �I�TIFIATE OF L,9� 11..6T1° IIV ,11AIV�� SCOTC50 05 1$ 07 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION GOLD MAN & ASSOCIATES INSURANCE ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE FINANCIAL $ERVICES INC. HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR 933 FAI.MOVTH RD. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW HY.ANNIS MA 02601 Phane: 508-775-6010 rax:508-790-0249 INSURERS AFFORDING COVERAGE NAtC# 1N9uRED INSURER A; �PENN-AbORICA INS. CO. INSURER 8: CRAIG SCOTT INSURER C: — PO BOA 1987 INSURER D: MANOMET MA 02345 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 DOCUMFNT 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 ANO CONDITIONS OF SUCH POLIMES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, _LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE MM/DD/YY bA7E MMlDDM( LIMITS GENERALI•IAINLITY I EACH OCCURRENCE �01�0�00 A X COMMERCIAL GENERAL LIABILITY PACS 025 3 0 5/19/07 ' 0 5/19/0 8 PREMISES Ea odourence $50000 CLAIMS MADE I" I OCCUR MED EXP(Any one person) 5000 PERSONAL BADVINJURY $1000000 GENERAL AGGREGATE 3 2000000 GEN'L AGGREGATE LIMIT APPLY$PER' PRODUCTS-COMPIOP AGO S 10 00000 POLICY T0 LOC - AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S ANY AUTO (Ea accldanl) JI ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTO; (Per person) HIRED AUTOS BODILY INJURY S (Poe oeoldonl) - � NON•OUJNED AUTOS -� lPROPERTY CAMA(3E F S (Per accident) CARAGELIA01UTY AUTO ONLY-EAACCIDFN''T F ANY AUTO OTHER THAN EA ACC S _ — AUTO ONLY, AGO-$ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ❑ CLAIMS MADE AGGREGATE $ S DEDUCTIBLE RETENTION WORKERS COMPENSATION AND TORY LIMITS FR EMPLOYCRS'LIABILITY E.L.EACH ACCIDENT S ANY PROPRIETORIPARTNERIEXFCUTW, OFFICER/MEMBER EXCLUDED? Ill.DISEASE•EA EMPLOYEE $ FPE'7,det.fto and?r SCIAL PROVISIONS beirnv El,DISEASE•POLICY LIMITT OT14PR DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES!EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS WORKERS COMPENSATION COI TO FOLLOW DIRECTLY BY CARRIER CERTIFICATE HOLDER CANCELLATION MIKE EN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BErORE THE EXPIRATIO DATE THFRFOF,THE ISSUING INSURER WILL eNDEAVOR TO MAIL 10.a -'DAYS WRITTEN NOTICE TO T CC-RTMICATE HOLDER NAMED ILURE I DO SO SHALL z�zz RINzz 50$-� 8 950 a IMPOSE NO O L GATION IABILITY OF Y KIND UPON THE INSURER,ITS AGENTS OR 387 PHTNNEYS �E REPRESEN7A IV 5. CENTERVILLE MA 02632 AUTHORIZED PZE NTATIVE ANN LOtJIELANG ACORD 25(2001108) 4:)ACORD CORPORATION 198 Z 006 03 02/.2006 09:25 FAX 508 586 3700 BEAR_CE @PEST — — DATE -- ---- :--'� oZn7izoo6 CCO��MERCIALNSL�1R�► ICAP�L.ICATION - �pPLIGANT INEOR TIO SE TIO _ uNDERw L f 586-3400 'cR �NAIC COME: — ____ -• --' — PRooucER .,--:--• F )•-056' 586-3700 REnu •---- ---- __ AX � � POLICIE90RPROORAM -.,,,-- Searce Insurance r _ . ----• -' GARAGE AND DEALERS 670 Pleasant Street - - TTA--^CHED :Eau+PMENY FLDATER vEmc-LE SCHEDULE INOIGATESECTIONSA _ INSYALIA71OWBUILDER5RISK p. 0. BOX 1709 ;PROPERTY -- i BOILER&MACHINERY Brockton, NIA 02301 1 1 ELECTRONIC DATA PROC I GLASS AND SIGN --;COMMERCIAL i WORKERS COMPENSATION _ .._. •-•-• --"" TY ACCOUNTSRECEIVABLE/ `.. ;GENERALLIABILI ••��- VALUABLE PAPERS UMBRELLA CODE: i SU8 COPE: I CRIMEIMISCEUANEOUS CRIME ;- i BUSINE6S AUTO AGENCY CUSTOMER 10 i TR TNSRPORTA710NIR TRUC 3�OTOR CARRIER 00007570 PACKAGE POLICY INFORMATION _ uxES OR FOa MONOUNE p0uc1ES. 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CONSULTANT _ 2. ASSESSOR'S MAP 45 l ! N/F ROBERT FELDMAN € ) PARCEL 040 2 t DEED BOOT. 24687 PAGE 267 PARCEL ID: 245--041 } ! RECORD DEED: BOCK 26M PAGE 125 1 1 RECORD PLANS: BW 34 PAGE 23, NUCLIDES L075 318, & 320 BOCK( 117 PAGE 21 LOT 318A LOCUS SUBJECT TO E401EN15: BOOK 783 PAGE 304, BOOK 745 PAGE 67 � i t CONSULTANT 0 74 OW AR. 231 FIFTH AVE I.I.C. AIDE HOUSE G /PROPOSED GARAGE I \ '� 3.) PROJECT BENC NW- AS SHOWN ON THIS PLAN NLL 'Y u.. PROPOSED LIMIT OF WORK \ N 87-2136" •r li I }, FOR HOUSE CONSTRUCTION , o ��1 h.s 4.) ZONING MIFORMA110N: � �` TOOL -� � �. a i z ss Cn �, j: ZONWG DISTRICT : RB PREPARED F'<O R : \, Q �.. Z, 1 CURREM MINIMUM ZONING REQUI2EIIENTS. \ :::::": = EXISTING o C , ! m � PROPOSED STAIRS � h � 6$ ,\ � • W � INN. LOT AREA = 43,560 S.F. WITH LANDINGS .� a : <:::. PAVED a� 6. MIN. LOT FRONTAGE Co N/F PiATRICIA E. BRADLEY E REV �' i.a :::.. D EWAY 231 Fifth Ave ,LLC D BOOK P 2 AN. LOT WIDTH = 100 �, , DEED B �0598 ACE v72 a - � � w i FRONT YARD = 20' S& h REAR Y = 10' i PARCEL ,�: 245-042 xs.z c% Centercor ,. • N/F Br'�RBARA KLAMAN, TRUSTEE ` ' 4 DEED BOOK 12281 PAGE 64 _ ":•:: :: \ 0.1 PARCEL ID: 245-1,144 A s `T w OVERLAY DISiRK'75. • AP 600 Loring Avenue ��3 EXISTING w G%4 5.) A TITLE SEARCH HAS NtTT BEEN PERFUMED FOR THS SM THERE MAY BE RIGHTS BY OTHERS, \f- xS:B oPO� DWELLING U, Salem MA 01976. TOP OF COAST � A7E & T WN 1 , H 6.s _..___.. _ �-•.... 4 s ` i+•� EASEl�M TAKINGS, M(MiTGAGES, RIGHT' OF WAYS ETC. NOT DEPICTED. IF DE?ERINNED lro BE � �\ , STAIRS �, #231 <_, �, -. _ r k I NECESSARY, A TITLE SEARCH SHALL BE PERFbRMED BY OTHERS AND SUPPLED TO BAXTER NYE i7� 1 � 21.9 ' w i :;. J N 87'21'36 E - - - 40. .* THRESHOLD U R yL , s9V EL.W 8.g ::: ::::: a U� 6.) THE PROPERTY UK INIDWTION SHOWN IS BASED ON CURRW AVANABIE RECORD EN V M11ON 282.00'± DEED '�` -' , �> _V -10 ti PROPOSED :......:=_: CONSISTING OF PLANS AND DEIDS. THE EXfS1ING fEAiURES SHOWN HEREON WERE OBTi U FROM ,� AL �, x4.5 RINSE STATION :::::::: ( hPPRox. �,•� AN ON THE GROUND MD SURVEY PERFORMIEO BY BARTER NYE ENGINEERgVG SURVEYING ON AL �\ � " x5� =` SEPTIC w APRIL 13, 2017. AL ,L \ ff Xs� 1 (.LOCATION V AL AL AL AL 'L �\•'2� f > % 7.) OOMIMMNN(1Y PANEL NUMBER: 250001 0564 J, EFFECTIVE DATE JULY 16, 2014 AL s m i 6 THE FLOOD INSURANCE RATE MAP OEMTN1S AREA AS ZONE AE (EL 12), ZONE AE (EL 13), AND �\ ZONE VE (EL14). Xj HALL'S CREEK "S 4,0 �AL 10 00 - IRE III. •. i GUY V. i k , i >, AL _ WF-O6 - U P 250.U0 t DEED S 87'21 _ _ JC.3-�16 N _,� 5 r._ ;-- ---_ . PER MASS GIS OUVER AS OF 04/28/17 AND 10/17/17: +� � 8%°21'36" W $ YYf-05�..',� 11E� z`- 03 PROPOSED DECK J �'" � ��, '� I 1 • SITE iS NOT WITHIN AN A.0 E:C. (AREA OF CRITICAL ENVIRONMENTAL CONCERN) PER MASS �� 0�°����° WITH STEP \ j GIS OLIVER AS OF 04/28/17. 0 1� 1 SITE DOES NOT APPEAR WITHIN AN AREA OF ES71MAIE D HABITAT OF RARE WILDLIFE AS EDGE OF HALLS CREEK PER $ f i \\ '\ 1 MASS GIS OLIVER �'•,- .1 C� ��'� ' \ MAPPED ON MASS GIS OLIVER AS OBTAINED ON 10/17/17 'ESTIMATED HABITATS OF RARE ,p •'L [ SURVEY NAIL \ \ OSED ; ELEVATION 6.54 FEET WILDLIFE' FOR USE WITH THE MA WETLANDS PROTECTION ACT REGULATIONS (310 CUR 10)." ,a r COVERED PORCH ; NAVD88 'L9 ° • SITE DOES NOT APPEAR TO CONTAIN A CERTIFIED VERNAL POOL AS MAPPED ON MASS GIS 'L c' N/F ROBERT W. WONG, TRUSTEE 44 r . Q �G °y 2� 241 FIFTH AVENUE REALTY TRUST I ON 10/17/17 PER NHESP CERIIFlED VERNAL POOLS f q ° OLIVER AS OBTAINED \ DEED BOOK D: 24 PAGE 8 . SITE DOES NOT APPEAR TO BE WITHIN A PRIORITY HABITAT AS MAPPED ON MASS GIS ��,;• ��, PARCEL ID: 245-oss OLIVER AS OBTAINED ON 10/17/17 PER NHESP 'PRIORITY HABITATS OF RARE SPECIES" FOR SPECIES UNDER THE MASSACHUSETTS ENDANGERED SPECIES ACT, REGULATIONS 0 (321 CUR 10). w C �• J ^+ •rj) ' SITE DOES NOT APPEAR TO BE WITHIN A STATE APPROVED ZONE 11 GROUND WATER ~ W> RECHARGE PROTECTION AREA PER MASS CIS OLIVER AS OF 04/28/17. I- Q C • SITE DOES NOT APPEAR TO BE WITHIN A ZONE OF CONTRIBUTION TO A SALTWATER ESTUARY v t (BARNSTABLE B.O.H.!REG. 360-45) PER TOWN OF BARNSTABLE MAPS W LL .� _ U) 9.) UTILITY INFORMATION `MdE6El� th a N � Ot/4tEQ wnoo STAKE AT as O/C OR } THE CONTRACTOR SHALL CONTACT DiG SAFE (AT 1-888-DIG-SAFE) AND UTiUTY COMPANIES TO LOCATE THE LOCATION OF ALL EXISTING UTILITIES, AT LEAST 72 HOURS PRIOR TO THE START OF CONSTRUCTION. EXISTING UNDERGROUND INFRASTRUCTURE, UTILITIES, CONDUITS AND LINES ARE SHOWN IN AN APPROXIMATE WAY ONLY, MAY NOT BE LIMITED TO THOSE 1MRAFl SILT FENCE (MIR/1Fl t00X) i � Z OR APPROVED EQUAL 2'x 2'x S WOOD STAKE, SHOWN HEREIN AND HAVE BEEN RESEARCHED BASED ON THE AVAILABLE UTILITY RECORDS s Wx S' REINFORCING STEEL NOTED HEREON. 71'1E CONTRACTOR AGREES TO BE FULLY RESPONSIBLE FOR ANY AND ALL o OR APPROVED EQUAL DAMAGES WHICH ALIGHT BE OCCASIONED BY THE CONTRACTOR'S FAILURE TO LOCATE SAID F- INFRASTRUCTURE AND UTILITIES EXACTLY. IF FIELD CONDITIONS DIFFERS FROM PEAK a. INFORMATION, THEICONTRACTOR SHALL NOTIFY THE ENGINEER IMMEDIATELY FOR POSSIBLE z w REDESIGN. 0 0 AL SOURCE INFORMATiCN FROM PLANS HAS BEEN COMBINED WITH OBSERVED EVIDENCE OF w U' PROTE --' UlIU71ES TO DEVELOP A VIEW OF THOSE UNDERGROUND UTILITIES. HOWEVER, LACKING z AREA - - EXCAVATION, THE EXACT LOCATION OF UNDERGROUND FEATURES CANNOT BE ACCURATELY, (WETLAND) s ��-' •� WORK COMPLETELY AND PELIABLY DEPICTED. WHERE ADDITIONAL OR MORE DETAILED INFORMATION IS AREA REQUIRED, THE CLENT IS ADVISED THAT EXCAVATION MAY BE NECESSARY. w AL STA® STRAW SALES D.E.P. File #SE 3- �� -'t ,, " 'y'.3 r SCOTT S. SHIELD EMSTING SEPTIC SYSTEM FILE AT BOARD OFATION TAINED FROM HEALTH. SEPTIC SYSTEM AS-BUILT CARD BY o �� �- , Order of Conditions Expires: f 2-S•-Z 02 0 '�` / Flow m � TOWi1N WATER SERVICE SHOWWN ON THIS PLAN FROM WATER DEPARTMENT SKETCH 0373 TOP OF AL SET 4- IN110 SUPPLEMENTED WITH FIELD LOCATION OF WATER GALE. o GROUND GROUND.� CONSERVAT�N NOTES: z GAS SERVICE SHOWN ON PLAN PER NATIONAL GRID MAP, SUPPLEMENT® WITH FIELD LOCATION SHEET TITLE 1. NO WORK IS TO BE DONE UNTIL FORMS A & B ALONG WITH REQUIRED 4. T OF GAS GATE A: METER. < PHOTOGRAPHS ARE SUBMITTED TO CONSERVATION COMMISSION. Ch 2. LIMIT of WORK SHALL CONSIST OF snRAwBwFs AND SILT FENCING N • ELECTRIC LINE SHOWN ON THIS PLAN PER EVERSOURCE MAP INDICATING UNDERGROUND Wetlands Permit Plan SERVICE FROM UTILITY POLE 405-14, SUPPLEMENTED WITH FIELD LOCATION OF METER. TO BE MAINTAINED IN GOOD REPAIR UNTIL COMPLETION OF PROJECT. (MIN.) �- (TAN.) Proposed Additions p N 3. ALL ROOF LEADERS SHALL DISCHARGE TO DRY WELLS OR DRIP TRENCHES. ' N 4. ALL MATERIALS FROM HOUSE REMODELING SHALL BE HAULED OFF-SITE SHEET NO AND DISPOSED OF IN ACCORDANCE WITH APPLICABLE REGIH,A71ONS. 3 no D A T E : NOVEMBER 13, 2017 N 20 0 20 40 0 J J c- OLT A /STRAW BALE (UMIT OF WORK)N.T.S. SCALE IN FEET SCALE : 1"= 20' ot ,$ S '?; rn L. DRAWN/DESIGN BY: JKL CHECKED BY: SW 0 J O B NO: 2016-M C A D D F I L E: 2016-046WPP. o 0 N .0