HomeMy WebLinkAbout0105 FRANKLIN AVENUE �o� ,�i�-��k 1��, A ire,
i
Town of Barnstable
�1HE Regulatory Services
Thomas F.Geiler,Director
" CAB ' ` Building Division
1D639. Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
PERMIT# O�D 13 6 3��� FEE: $
SHED REGISTRATION
RESIDENTIAL ONLY
200 square feet or less
Location of shed(address) Za
CAO
Property owner's name Telephone number
Size of Shed Map/Parcel#
� A /Zu
i ature Date 4 c
Hyannis Main Street Waterfront Historic District?
y
r
Old King's Highway Historic District Commission jurisdiction?
If over 120 square feet,you must file with Old King's Highway yam!
Conservation Commission(signature is required)
Sign off hours for Conservation 8:00-9:30&3:30-4:30
PLEASE NOTE: IF YOU ARE WITHIN THE JURISDICTION OF ANY OF THE ABOVE
COMMISSIONS,THERE MAY BE A REVIEW PROCESS AND APPLICATION FEE.
PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS.
THIS FORM MUST BE ACCOMPANIED BY A
PLOT PLAN
Q-forms-shedreg
REV:052813
Map N-._ Page 1 of 1
Jt
Town of Barnstable Geographic Information.System New Search Home Help
Parcel Viewer Custom Map Abutters Map Size Zoom Out ®In
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7PG- selecting check boxes below - -
. ,N17 "
292279 $ - Town Boundaries'
-202274
r, Road Names _
Voter Precincts292280
_r"Map&Parcel Numbers
F TM
� Parcels r^^
292273 r, FEMA Q3 Flood Zones(Current Maps)
-
QNot for official flood hazard determination.
292106 AE(100 yr flood)
AO(100 Yr flood)
VE(100-yr flood w/wave action) 4,.
rX500(500 jr flood) s
FEMA Preliminary May 2013 Zones(subject to change)`�;
" 292277 _ Expected Adoption Summer 2014 a
AE-100 year flood '
292271 AO 100 Year flood. -
0 a 1 n4 5 F et
292107
pse VE-Velocity Zone
0.2%Annual Chance Flood °r
Open Water` `
Sea Scale i"=45 { Aerial Photos TMAP DISCLAIMER
Copyright 2005-20707own.of BamstaDle,MA All rights reserved.Sendquestions o{comments to GIS
-. BarnstableMA v1:2.4748(Production) -
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http://66.203.95.236/arcims/4ppgeoapp/map'.aspx?propertyID=292273 6/4/2013
t
Town :of Barnstable 1 *Pe
hrn r issue dale
L. . PERMIT
R�egula_tory Services F Fee e �
9 16 9. �� Thomas F.Geiler,Director..
r 3
19 2012
Building,Division
Tom Perry,CBO,'Building,Commissioner
TOWN OF BARNSTABLE 200 Main Stieet,.Hyannis,,MA 02501 "
www.town barnstable,ma us
Office:.508-862-4038 Fax: 508-790=6230
EXPRESS PERMIT APPLICATION - RESIDENTIA_L ONLY
//�� Z Not Vadd without Red X-.Press Imprint'
Map/parcel Number- �",l21
.2 `3
ProPerty.Address ( dO6.
❑-Residential Value of Work . Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address S (�
Contractor's Name _ Telephone Number
Home Improvement Contractor License#(if applicable)
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance
Check one:
❑ am a sole proprietor
am the Horpeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name "
Workman's Comp. Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Pemut Request(check.box) 6
❑ Re-roof(hurricane nailed)(dripping old shingles) All construction debris will be taken to
❑Re-roof(hurricane nailed)(not stripping. Going over existing-layers of roof)
Re-side
#of doors . ..
Replacement WindowsMoors/sliders.U=Value (maximum 35)#of windows
Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required: .
Separate Electrical&Fire Permits .required.
*where required:.Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
- ***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License&'Construction Supervisors License is
i
SIGNATURE: -
Q:1wPFTL ES\FORM51bu$d s permit forms' dnc
�I, r Town, of Barnstable
Regulatory Services
3ARNSrABLE Thomas F.Geiler,Director
MASS.
1639. Building Division
ArE pl A
Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-403 8 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Q Please Print
JOB LOGATfON: �(�S� c TGJ fell!/t
number street. village.
"HOMEOWNER": I;kK) � R
name home phone# work phone#
CURRENT MAILING ADDRESS:
city/town state zip code
The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and
to allow homeowners to engage an individual for hire who does not possess a'license,provided that the owner acts as
supervisor. i
DEFINITION OF HOMEOWNER
a `-PersoriQ,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 ana or farm structures. A'
person who constructs more than one home in a two-year period shall not be considered alhomeowner. 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.
applicablmodes,bylaws,rules and regulations.
The undersigned."homeowner"certifies that he/she understands the Town of Barnstable Building Department
agnatinspection procedures and requirements and that he/she will comply with said procedures and
ure
ome wner,
......... �.
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.person(s)for hire to do such
work,that such Homeowner shall act as supervisor.
Many homeowners who hse.this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,
Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results,in serious-problems,particularly -
when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed.
Supervisor. The homeowner acting as Supervisor is ultimately responsible. '
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,
that the homeowner certify that he/she.understands the responsibilities of a Supervisor. On the last page of this'issue is a form currently used by
several towns. You may caret amend and adopt such a form/certification for use in your commumty:',
Q:forms:homeexempt '
oFIME ram, Town of Barnstable
~ Regulatory Services
•. snRNWANA, •
y Mnss �, Thomas F. Geiler,Director
�
s6
1639 0
9.� '� 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
1
Property Owner Must
Complete and Sign This Section
If Using A Builder
as Owner of the subject property
hereby authorize to act on my behalf,
in all matters relative to work-authorized by this building permit:
(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
Q:FORMS:OWNERPERMISSIONPOOLS 6/2012
The Commonwealth of Massachusetts
Department of Industrial Accidents
' Office of Investigations
+ d 600 Washington Street
Boston,MA 02111
�H 5 www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):
Address:
City/State/Zip: , 0QC,G( Phone.#:
Are you an employer?Check the appropriate box: Type of project(required):.
1.❑ 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
listed on the attached sheet. 7. Remodeling
ZAJ am a sole proprietor or partner-
ship and have no employees These sub-contractors have 8. ❑ Demolition
workingfor me in an capacity. employees and have workers'
Y P ty 9. ❑Building addition
[No workers' comp.insurance comp.insurance.$ ,
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.El am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.❑ Other
comp.insurance required:] .
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. 5
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. #
Insurance Company Name:
Policy#or Self-ins. Lic.#: Expiration Date:
Job Site Address: City/State/Zip: . -
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure.to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the fort of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certi under the pains and penalties of perjury that the information provided above is true and correct.
Si aiure: Date:
Phone k tS b8 2GO YS 1-(
Official use only. Do not write in this area, to be completed by city or town official
City.or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk. 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions l
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other:legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides,.thei6n,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
}
MGL chapter 152, §25C(6)also states that"every state or local licensing agency*shall withhold the issuance or .
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for.the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
j, insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials.
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in _(city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for our cooperation and should you have an questions,
g Y Y ,
P Y Yq
please do not hesitate to-give us a call.
The Department's address,telephone-and fax number: a
The Commonwealth of Massachusetts t.
Departrnent of Industrial Moi&nts
Office of Investigations
600 Washington Street
Boston, MA 02111
1
Tel. ##617-727-4900 ext 406 or 1-977-MASSAFE
Revised 11-22-06 Fax##617-727-7749
www.mass.gov/dia
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington:Street
Boston,MA 02111
•Y•�,. www.mass.govld'
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le 'bl
Name(Business/Organization/Individual
Address: M
City/State/Zip: Ohl rS C) PhoneA 5'0 `�/2
Are you an employer? Check the appropriate box: Type of project(required):.
1.❑ I am a employer with 4. eI am a general contractor and I
_ 6. ❑New construction .
employees (full and/or part-time).* have hired the sub-contractors
2:❑ I am a sole proprietor or partner- listed on the attached sheet: 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑'Demolition
workingfor me in an capacity. employees and have workers'
Y P t3' 9. ❑Building addition
[No workers' comp.insurance comp.insurance.
I required] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152,§1(4),and we have no
employees. [No workers',
13.n Other
comp.insurance required.]
*Any applicant that checks box 41 must also fill out the section below showing their workers'compensation.policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information
Insurance Company Name:
Policy#or Self-ins.Lie.#: - Expiration Date:
Job Site Address: City/State/Zip: _
Attach a copy of the workers' compensation policy declaration page(showing the policy number.and expiration date).
Failure.to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a:fine
of up to$250.00 a day against the violator: Be advised that a copy of this statement may be forwarded.to the Office of
Investigations of the MA for insurance coverage verification.
I do hereby;ce "Zunr the pains and penalties of perjury that the information provided above is true.and correct
Signature. Dater ltr
Phone#:
Official use only. Do not write in this area,to be completed by city or town offcciaL
City or.Town: Permit/License# i
Issuing Authority(circle.one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.PlumbingTnspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. ,
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written.
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual;partnership,association or other legal entity;,employing.employees. However the
owner of a dwelling house having not more than three apartment's and who resides,, or the occupant of.the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be'deemed to be an employer."
MGL chapter 152, §25C(6)also st tes that"every state or local licensing agency shall withhold the issuance,or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for.the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presentedto the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s) along with their certificate(s)of
insurance. Limited Liability Companies'(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers'compensation insurance. If an LLC.or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials.
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in _(city or
town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit mustbe filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address,telephone-and fax number:
The Commonwealth of Massachusetts
Dgparftne"tt of Industrial.Accidems
Office of Investigations
60...0 Washington Street
Boston, MA 42111
Tel.#617-727-4900 ext 406 or 1-977-MASS.AFE
Fax#617-727-7`�49
Revised 11-22-06 '
www.mass.gov/dia
r
CAPE COD TOWN
INSULATION
25
El
!iBlQ OtASS SVQAY FOAM SUSY[N 90
BATTS INSULATION C[IlIN05
1-800-696-6611
D VI S If!
'Fown of Barnstable
Regulatory Services
Building Division
200 Main St
Hyannis, MA 02601
- - - Date:._7._�.y—)o�
Dear Building Inspector
Please accept this Affidavit as documentation_that Cape Cod Insulation, Inc. performed &
completed the insulation and weatherization work at the property listed below. Cape Cod
Insulation did this in accordance to the specifications listed on the building permit
application. All work has been inspected by a certified Building Performance Institute
(BPI) inspector. All work preformed meets or exceeds Federal & State Requirements.
Pro ert Owner Property :address Village
e r�s �►� �� Io S Ryoq>u0IS
I�eCm�fi � rS ao�ai�8S
Insulation Installed: Fiberglass Cellulose R-Value . Restricted Unrestricted
Ceilings
Slopes ( ) ( ) ( ) ( ) ( )
Floors ( ) ( ) ( ) ( ) ( )
Walls/S� 4 �
Sincerely
He y E Ca sidy r, President
Ca e Cod sulation, Inc.
Assessor's map and lot number .......:.................................. SEPTIC SYSTEM MUST BE
INSTALLED IN COMPLIM
V.`iTH A ,TICLE II STATE ;
Sewage Permit number .......................................................... SANITARY LOGE AND TOWN
REGULAT
yo�T�Ero TOWN OF BAR.NSTABLE "", :
i BARNSTLB E. i
oYa,��� BUILDING INSPECTOR
APPLICATIONFOR PERMIT TO u \...................................................................................................
TYPE OF CONSTRUCTION ................... .d. ":....-..... ....®.z�.1................................
? " .............................. 7
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information: �-
Location �,'� �-� ,CZ �� �`1. \\a......................
............................... ....................................
ProposedUse ...... . ......................................................................................................................I.........................
P����
...................................Fire District ..............................................................................
Zoning District .............�,..............a.-r�....�°-� ,y
J ® rL `_ �y� �.. ` Q 6 l 9 k � �,, �
Name of Owner .................. ... .................. ..r'.........Address ...........................................il. .
Nameof Builder ,h'�` ....Address................................................................ .............................................................................:......
Nameof Architect ..................................................................Address ....................................................................................
Numberof Rooms ..................................................................Foundation [..............................................................................
Exienor ...5 � -:�.............................................Roofing .....^.�.t�?.,"1�.....................................................
Floors ....i..`:ti--. ....L.. ......................................Interior ....: ..... ` ... ..... -t ....... .
Heating .. ..... :.. .................................................Plumbing ..... ............ ..., ..................................y �. ........
-
Fireplace ......... �� ...Approximate Cost ............ /.......... .........P.
Definitive Plan Approved by Planning Board -------------------------------- _______. Area ....:.................
...
Diagram of Lot and Building with Dimensions Fee �Or
SUBJECT TO APPROVAL OF BOARD OF HEALTH
Xef
r
r
lot,/
ILI-
7 7
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Name �.. ... ...�........... . ...........................
Coughlin, Joseph F.
one.�/stor7y
AU-� Franklin Ave.
Hyannis
----~---'—'-------^--------''
�� ' ~ ,
[�wmar ---�.�����---��������-----.
frame .
Type of Construction --------------
� ^
----.—.--------------------.
#1a�
Plot ---------. Lot --.����-----.
Permit Granted ���� J�� lg ��
---==~'^-�—'r--- ^~
�Date of Inspection ....................................
/ r !
--- Completed
'
` - -
= .
Lim
PERMIT REFUSED
'
.----._--.--_.--------- lg
�
--------------------------'
-~'-~--------'------------^—^— | -
\ �
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-----^'--------^^—'--^--'----'` '
�
.------~----------.--------.
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�
Approved .... 19
^
--------------....~-----~---. �
-------------------------...
'
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� '�
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
0 9Gr ParcelApplication Map �✓
� ryry
Ole�
Health Division Date Issued (_Z �v
Conservation Division Application Fee ,
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board P
Historic - OKH _ Preservation/ Hyannis 1
Project Street Address d ✓�
M Village
Owner �%�y .L/�//�'o Address
Telephone
Permit Request ,�� i�,�,2��Si2/cc� —,��� �y��✓.-s-e
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay R C
Project Valuation d Construction Type c C
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supp@in g docuT,7
,entation.
Dwelling Type: Single Family .X" Two Family ❑ Multi-Family(# units)
Age of Existing Structure Historic House: ❑Yes allo On Old Kings Highway: ❑YeS �NIO
I
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 Telephone Number
Address /t ,��f4�2d�r� C'//� License #
W a ij T� Home Improvement Contractor#
Worker's Compensation #
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
/fiYylO�/�
SIGNATURE DATE
y
FOR OFFICIAL USE ONLY
APPLICATION#
DATEISSUED
MAP/PARCEL NO.
1
ADDRESS VILLAGE
t OWNER
DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION
r FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
T FINAL BUILDING
DATE CLOSED OUT
t
ASSOCIATION PLAN NO.
i
i
r
y
Housing
Assistance ,
Corporation
Cape Cod
HOME OWNER WEATHERIZATION WORK PERMIT & FUEL RELEASE:
PLEASE FILL OUT AND SIGN THISFORM IFYOU ARE
THEAPPLICANT HOMEOWNER.
I r- L--A, hereby consent to and agreethat weatherization work
may be done by the Weafherization Program of H ousi ng Assistance Corporation
(herein after referred as Agency" on.the pro perty located at:.
The weatherization work done will be based on programmatic priorities and availability of
funding and it may includeall or someof thefollowing measures:
Weather-stripping & caulking of windows and door's, insulation of attics, sidewalIs&
basements, atticand other ventilation measuresand possibly replacement of badly deteriorated
windows. In consideration of theweatherization work to bedoneat'my homel agreeto the
following:
1. I givepermission to the"Agency" itsagentsand employeesto travel onto or acrosssaid
property with such equipment and materials as may'be necessary to perform
weatherizationwork on said property.
2. The Housing Assistance Corporation reserves the right to inspect the fuel or utility bill for
theweatherized unit on an ongoing basisfor no morethan five(5) years after the
weatherization work iscompleted.
I have read the provisions of,t his reement as listed and freely give my:consent: `
Home Owner: (1Slgnatur
Date: -7—
Agent:
(signature)
Dater I
HAC approved Weatherization Company : ncD
All Cape Energy, Cape Cod Insulation ape Save Efficient Buildings,LLC
. 11%.Rontier En,erigy,SQLutiart ,Lohr:& ,Sons , r, ;.:Resoltl,tion_ Energy
1 C` C.�C� � 2a� tT�(1S lrll �A /
L 10 Park Plaza - Suite 5170
i Boston, MasSc1C11LISettS 02116
Home Improvement Contractor Registration
Registration: 153567
Type. Private Corporation.
Expiration:. 12/15/2012 Tr# 206433
CAPE COD INSULATION, INC
HENRY CASSIDY
455 YARMOUTH RD.
HYANNIS, MA 02601 --
.-Update Address and return card. Marls reason for change.
L Address RenewalI Employment I Lost Card
S-CA1 0 7UM-04iO4-G101216
Officc.l o�auer AI't'airs 13us ne Regulatimi LiiV nSe or registration valid for individu!
HOME�O�fPb�m1fJ` �OIV1`RA � rwtr hcPr e the expiration date. if found return to:
Registration: 153567 Type: Office of Consumer Affairs and Business Regulation
- II' Expiration: 12/15/2012 Private Corporation 10 Park Plaza-Suite 5170
si C P P Boston,MA 02116
D INSULATION, INC
HENRY CASSIDY
455 YARMOUTH RD. U
HYANNIS,MA 02601 _.
Undersecretary t alid ith t si ture
lrusett -)epartinent of Public tiafeh
Board )t Buildin'. Rc!.,ulalions and ltuntlartls
Q3nstruction Supervisor License
_ m
Licerrs,: CSC 100988t
HENRY CASSIDY
8 SHED ROW
WEST 1.ARMOUTH, MA 02673
Expiration: 11/11/2013
Tr#: 7620
[• LVIL J . IIfIVI _ No, 1605 P.
Client#:4597 ACCINSUL
ACORD,,, CERTIFICATE OF L�ABI .1TY INSURANCE DATE(MM,DDfYYW,—
THIS CERTIFICATE 15 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NOR 07/0212012
RIGHTS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELYAMLNP,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES S
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 ie an ADDITIONAL INSURED,i w policy(ies)must be endorsed.II SUBROGATION IS WAIVED sub oct to
the terns and conditions of the policy,certain pollcles may rugL14u an endor5ament.A etatement on this certificate does not conferrigh(s to the
certificate holder in lieu of such endarsernenl(s).
PRODUCER '
Rogers&Gray Ins.-So.Dennis NAME: Mal' aret Youn
PHONE
434 Route 134 NC Na Exl:508-760 4602 A/C No 877-81ti•2'15G
E-MAIL
South Dennis, MA 02660-%01
508 398-7980 _INBURER(B)AFFORDING COVERAGE NAIL d
INSURED^ _..___ IN$URERA,'Peerless Insurance 18333 -
Cape Cod Insulation Inc INSURERB:Evanston Insurance Company `
455 Yarmouth Road INSURERC:Atlantic Charter Insurance --
Hyannis,MA 02601 INSURER Dr.Cam��,,vuwurance Company 34754
IN3URERE:___ �NbURER F:
COVERAGES CERTIFICATE NUMBER: `
REVISION NUMBER;
THIS IS TO CERTIFY THAT DINE ANY RE OF INSURANCE LISTED hELg41' hiAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
CERTIFICATE
NOTWITHSTANDING B IS7ANDING ANY REQUIREMENT, TERM OR GONf.ITICIN OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE (SITED OR MAY PERTAIN. THE INSURANCE,aFForDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL ThIE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHpwN rnAY HRV�BEEN RGpUCEp BY PAID CLAIMS.
R TYPR OF INSURANCE: ADDL SUBR - POLICY @FF pOLIGY EI( _
aaLlcv Nun+eER MMIDDlYYYY MMIDDNWY UM1TS_ A GENERAL LIABILITY - CBP9263083
410112012 04/01/201 EACH OCCURRENCE $1,000 000
X COMMERCIAL GENERAL LIABILITY ErITEq
�f � T aaccurrenco $1oo,aoo
CLAIMS-MADE ®OCCUR - .MEO EXP(Any ono Damon) $$000
PERWNN.&AOVINJORY $1 000 000
OENERALAG(IK(3ATE $2,000,000
GENL AGGREGATE LIM17 APPLIES PER;
POLICYPRO- [71 LOC - - PRODUCTS•COMPIOP AGG s2,000,000
AUTOMOBILE LIABILITY - 12MMBCKVNiK 4/01/2012 04/01/201' COMBINED SINGLE LIMIT
e5 arcidenl) 1 000 000
A1JY AUTO
ALL OWNED
SCHEDULED BODILY'INJURY(P..peron) q
AUTOS X AUTOS - - BODILY INJURY(Per A,iddont) S
X HIRED AUTOS X AUTOSWNED PROPERLY DA p
WWI
e X UNNRELLA LIAB OCCUR XONJ453512 4/01/2012 04/01/201 EACH OCCURRENCE $1 000000
eXcls6 uAB CLAIMS-MADE -
AGGREGATE $1,000,000
DEo I XI RETENTION 10000
C WORKERy COMPi!NBATION — $
AND EMPLOYERS'LIABILITY Y/N WCA0052590�� 6130/2012 U6/30/201 X WC STATU
ANYPROPRIE7O p 7N6 /XECUTIV&
OFFICEWMEM9ER Expl UO 7 I N f A E.L.EACN ACCIOFNT 1 000 U00
(Mandatory io NH)
If yea,deacnha under - E.L.DISEASE_EA.EMPLOYEE $1 Q00 Q00
DESCRIPTION OF OPERATIONS hclow -
_.--- E.L.DISEASE-POLICY LIMIT $1 000 000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Atlanh ACORb 101.Add III.—I tzar k.schod ls,4 more apace 18 rsNuOod)
"Workers Comp Infortnation "
Included Officers or Proprietors
Certificate Holder is included.as an additional insured unclor General Liability whan required by wrltten
contract or agreement.
CERTIFICATE HOLDER CANCELLATION.,
Cape Cod lnsulation,lne SHOULD ANY OF THE ABOVE DESCRIBED POLICIE$BE CANCELLED PEFORE
THE EXPIRATION DATE THEREOF, NOVICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE -
180 -2D1D AC )IZD CORPORATION,All rights reserved.
ACORD 25(2010/05) 1 of 1 The ACORD name and logo arc ragisterad marks of ACORD
NS83840/M83848
MEY
-- _ The Corr nofi ll , : lh of Massachusetts
Department l hJustrial Accidents
_= W Office ,4 /)1 vestigations
600 ll 1, rl> ton Street
Boar, , 1 A 0211.1
�Vurl.cr's t:urrxl��nation insaratice Affi i , �,: Builders/Contractors/Llectri�i�uts/.�'lttt�it►��r�
\Illllitant lnlurtuatiun Please 11rilit L,egihly
1 _
\;Ittt 11;ti�ut�ati/Or1;�tlllL."tall)!!/LI1Cl1V1tltlill�; t
_ wtV1V1 L; _D? _ Phone#: ��3 " �2
A c you an eutpluycrY (.'I►ecl: fl►c appropriate box: - _- ---�------
Type Of F)ru,jec.f(retluired):
i 1 and a rin[ luyer With 4, ❑ 1 am a,, u,.I'll contractor and l have 6. E] New constructiotl
eulployct�s (Full andlor part-tittle).*, hired the ,lii� contractors listed on 7, l:ernodeliug
ll the attach.:.1 .hi et.
—I I and a s,olc: Proprietor or partnership These sill :,I;tiactors have $• ❑ Demolition
ailed Ila- It,.)elnPIoyees working for employcc.:In,l have workers' comp. 9. ❑ Building addition
111C ill ally capat:ity. [No workers, insuraiic,.; 10, R .E1et;trtcal rCpollS of additiuus
C01111) IIISM'Ll it:e reflUired.J 5. We uc-.i i oi! nation and.its -
(( 11. ❑ hlurnl)iu rc irs ur additions
ant a honleowtter doing all work: exempno-iI I,t�IGL. 52t§i(4), and 12, Roof repairs
rs
tuysclf. [No I WOI'kelS' CUI1lp. we have'u„,r,ll,loyees. [No workers' 1
13. oth4r��cc.�r�l ej,l
nsur:uu:e required•J l comp. unl;,:u,x required.}
+mr,y,ph<Milt that cltec6:s box it I must also fill out the section below shn I iw o;vr workers'corilpensation Policy infornlatiorl.
I II.u,Gt,a1wis wtill,'subillit this alfiduvit'indicating they arc doing all tti Cal n,i I,a hiie outside collnactois I111.1Sl SUbl'illt a new affidavit inklicamig Sm;h.
nun 4 is that check this box trust attach an additional sheet showing d,, of the sub-contractors and state whether or not those entities have enlplu)rr, ll
<w1,,:uuua ours have clrtl)IJyccs, thay .lust pilovidc their workcts'cotly - hi number.
t out an crriployer that is providing workers'compensation uses Pules for my employees.Below is the policy and job site
n�(aruuuion.
Iluuranc t-Company Narae:
l't)h 11 to .�r.IC-ills lit. it: .02rA 00 h� 5-�I : _. Expiration Date.:
lull Sur ,ldtlrr.�s: . .. _.... City/State/Lip:
luadl a copy of like workers' coil ipensatiuu policy declaration pagt�(;h„tl-ing the policy number and expiration date:).
l ahltr W SOClll"C CUVeI'tkgC its required uncici-Section 25A of MGL c.I.5'-ill 1i:ad to the impo51non of criminal penalties of a fine ill)t0$1,50U.00 andlui
wirveat rinprlsunutent, as well as civil pcliaities in the form of a STOP R t w K ORDER and a fine of up to$250.00 a day against file violator. Be advistil
h.,t• cull of Uus statement ina e forwarded to the Office of Invesu,_,:t1j:.,,,„i the DIA for insurance coverage verification.
I do here c if under the , ins and penalties of't),:ri,r_v that the information provided above is true and correct.
Dafe:
17
I'huntaa: J
Officiul use unly. l:)u nut write in titis circa, to be completed bI,c,ty or tuiwl official
City l" 'Cuwu: _ I't rmit/License# —
Issuing;Authority (circle one):
1.Mooed of Health 2. ttuilding Departmetlt 3.Cits/Vito it Clerk 4,Electrical inspector S.Plumbing hlspeclor
b.Uther
l'untact Nrrsurl: __..... Phone#: _—