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0093 GREENWOOD AVENUE
�I TOWN OF BARNSTABLE BUILIJING PERMIT APPLICATION Map � Parcel Application Health Division Date Issued g ` Z� - r3 Conservation Division Application Fee V Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address 93 C�,- r-e--e h C,X©od� a V 4 Village Owner M V61� 0, Add re �!� C, �� UAnc-A Telephone JZ'bo — �' (&b g ���'R-�✓Ic c�va j' Permit Request -: R 66-1 Square feet: 1 st floor: existing I proposedS2nd floor: existing �� proposed-S61- Total new ,Von e Zoning District Flood Plain Groundwater Overlay Project Valuation A0i0'0 00 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: >�J'Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) I �� Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing —new a o ::E Total Room Count (not including baths): existing ?S new First FloorU om Count Heat Type and Fuel: W(Gas Oil ❑ Electric ❑ Other o, Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing woo coal stone: Les ❑ No Detached garage: ❑ existing ❑ new size Pool: ❑ existing ❑ new size _ Barn: ❑ existing :_O net size_ � rn 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" t> APPLICANT INFORMATION (BUILDER OR HOMEOWNER) ., IIA• Name CIE e r k C\_6> Telephone Number "fig -7 7 Address 4,9 License # /9 Home Improvement Contractor# l 1 00 Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATU DATE `7 4 FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED ' MAP%PARCEL NO. s:= j -ADDRESS VILLAGE x OWNER i J DATE OF INSPECTION: f. ? FOUNDATI.QN4r� �:t ,k�.� FRAME ._. .., -�41_NSULATION. FIREPLACE ELECTRICAL: ROUGH FINAL - M PLUMBING: ROUGH t FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSEDOUT ' ASSOCIATION PLAN NO. lot., s ' The Commonwealth ofMassachusetts Department of IndustrialAccidents �. Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia r' Workers' Compensation Insurance Affidavit: Builders/Contractors/Ele'tricians/Plumbers Applicant Information Please Print Legibly Name(Business/Organization/Individual): k�, w /" V r�N Address: C City/State/Zip: NAbUY 6 0 4 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 employees(full and/or,part-time).* have hired the sub-contractors 6. 0 New construction 2.5 I am a sole proprietor or partner listed on the attached sheet. 7. Remodeling shipand have no employees , These sub-contractors have g. ❑Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp. insurance.$ 9. ❑Building addition required.] 5. ❑ We are a corporation and its 10.to 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.❑ 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. *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 andjob site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP.WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certi under the pa ns and pen es of p rjury that the information provided above is e t: /and correct Si afore: 4a Date: /S /o Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: I Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant-to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance.coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact 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 permitilicense 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 Tel.#617-727-4940 ext 446 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia �TME Tay, Town of Barnstable Regulatory Services HARxsT"M MASS. Thomas F.Geiler,Director i639• ,�� 16.19 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 , I, ► / ►���z �G� ,as Owner of the subject property hereby authorize ll f LS�P 11 t�\ �S 7 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. I Sigr4ture of Owner Signature ot Applican �n� G (A r Print Name Print Name •7 /S / D to Q:FORM&OWNERPERMISSIONPOOLS 6/2012 r Town of Barnstable , Regulatory Services NUBS.. Thomas F.Geiler,Director g omas , Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230. HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village ••HOMEOWNER": •{ name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code 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 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. C:\Users\dewUdcdAppDataUcal\MicrosoR\Windows\Temporary Internet Files\ContentOudook\QRE6ZUBNIEXPRESS.doc Revised 053012 - tpsE §xz'` z x;ban.005% t 3 t a z t • ,c r3 fi r r •� 1M''J3" 'y'�f� 4ST 1 M1 m t t fy,,eq ` 2� i L elf K. v>;.� n Y` ay t§y"'v qf' ''=fir 4 F !y3 r�Yt-y T N r # .. �r W-11 14 ,;s'�`>iY1T Nf" fh.! c`aYr nAa` 1r`4^kl'•Lw^a?+!+ t yt'�s4+14..fw.'Tr3t ii:N'1vT°'Yy-`:f4�' 7 i?w*c•`M1',� F..a. �y 7 .:k ...• _� ��,: 'emu. .R,x+z"'WSJ:t�� '€g.��� 4CJ .✓ras''rl�t.fl�r P`'.9 �.. :.... - .Qt M q & ! 1'fiy1�ti I�lat; i >ifl I,sr F"ia� '"9•h ai! 1'tt��A4' �9N '. '.Sn.0 al a�f Bualalinq� Rc«ui atairn,° dial dnGlalf,u� Construction Supervasot' License License: CS 76647 CHRISTOPHER A KIRITSY 2 21 OXFORD-.ST NORTH Y.I AUBURN, MA-0150,1 ' Expiration 7/23/2013 C:�mnuSsiuniii TO 18080 77 �. T�7- pp ✓�+� License or registration valid for indrvadul use only ✓�ie"CVo ravnioaaur ti,., Oeu of Consumer Affairs „B smess Regulatton before the exparat►on.date If found return to. 4 HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation ` 12egistrataon 71300 Type y Expiration: `3/6/2014 Individual �' l0 Park Plaza` Suite 5170 I Boston,MA 02116 C l OPHER A�K' tRITSY F" 4 s CHRISTOPHER KI ITS 1 t i 21 OXFORD STREET'NCORTyH i AUBURN MA 01501'f Unalersecret�ry Not valid without signature • ti N7 fio.0 Tot Budding Rcpulattt)ns�amI tant9arA is `a Construction Supervisor. License Ail? License: CS 7664.7 rya -� CHRISTOP,HER A KIRITSY .21 OXFORD',ST NORTH. ' AUBURN, MA.:01501 ` .a EzPirat� 7/23/2dn � Cununic4io ne.1 8g80 omUnwouue o�` zaaac/uaeltaT' _ License or registration valid for indrvidul use only Office of Consu' rs. B smess'Regulahon HOME IMP MENT C TRACTOR = before the expiration date If found return to'- TOR Office of Consumer Affairs and Business Regulation .Registra,' n ;y 1,7 0 10 Park Plaza=Suite 5170 t t Expirati 3/6/2014 Ini9lvld.ua .. n' Boston,MA 02116 C TOPHER tk CHRISTOPHER KIRITSY �j 21 0XFORD:,STRE T'- J,F 7 f AUBURN MR`01501 - ,t Undersecretary Not valid without signature a , A 5F Y + „7 i i; ii is :i j Commonwealth of Massachusetts Sheet Metal Permit Ma2E2 Parcel 0 9q%f PA-PRESS PERMIT Date: ' 7� J' Permit# 0, `-e --AUG162013 Estimated Sob Cost: $_'2-S-0 m Permit Fee: $ Plans Submitted: YES NOF&N OF BARNS P " viewed: YES NO Business License !F Applicant License 4 Business Information; Property Owner/Job Location Information: Name: �� � ! �L Name. JMMK 11YU1-'W Street: City/Town: d. 4aoklib City/Town: Telephone. 7 Telephone:. Photo I.D.required/Copy of Photo I.D. attached: YES Z NO / staff Initial J-Y/lbf-l-unrestricted license J-2/,M-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft./2-stories or less Residential: 1-2 family ✓ Multi-family Condo I Townhouses Other Commercial: Office Retail Industrial Educational Fire Dept.Approval Institutional_ Other Square Footage: under 10,000 sq. ft. ✓ over 10,000 sq.ft. Number of Stories: Sheet metal work to be completed- New Work: Renovation: HVAC i/ Metal Watershed Roofing Kitchen Exhaust System Metal Chimney/Vents Air Balancing Provide detailed description of work to be done: - iNSURANCE COVERAGE: I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L Ch.112 Yes( la❑ If you have checked Y21,indicate the type of coverage by checking the appropriate box below: A liability insurance policy ( Other Type of indemnity [] Bond El 1 OWNER'S INSURANCE WAIVER:I am aware that the licensee does not have the insuranc overage required by Chapter 112 of the Massachusetts General Laws,and that my signature on this permit applicatio this requirement. Check One Only Owner ❑ Agent ❑ Signature of Owner ner's Agent i 1 By checking this box[],I hereby certify that all of the details and Information 1 have submitted(or entered)regarding this application are true and accurate to the best of-my knowledge and that all sheet metal work and installations performed under the permit issued for this application will be in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General laws. Duct inspection required prior to insulation installation:YES NO Prosr'esgssMeetio s Date Comments i I i i i Final i spection Date Comments j Type.of License: s 3y ❑Master s rbs ❑Faster-Restricted i �iry/Tawn ❑Joumeyperson Signaturej c�i � of Licensee ?errtit# m / —]Joueypersan-Restricted License Number: J :ee Check at www.mass-aovldail i nspector Signature of Permit Approval i =t Ike Cammonweah*of Massachusetts Department of I'nrlustriul Accidents Office of Invadgadons 600 Washington Street Boston,MA 02111 www.mass.gov/dim. Workers'.Con4)ensation Insurance Affidavit:Builders/Contractors/Electridans/PlumberS Applicant Information Pease Print L I . Name(B;isinesslOrganlzetionllndividnal}: i/ °r Address: ------------- City/State/Zip: Phone,#: lxg 7 Are you an employer?theck the appropriate box: -Type ofpioject(required):; i. ,am a employer with -4. ❑ 1 am a general contractor and 1` 6. ❑New construction . employees(full and/or part-tom).* have hired-1he sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on xhe'attached sheet. 7. ❑Remodeling i These sutrcontractors have g. Q Demolition ! shin and have m employees e�loye�.s and have workers' I working for me in any capacity. 9. Q Building addition { [No workers'comp.insurance comp.insuuance required] 5. �] We are a corporation and its =0❑Electrical repairs or additions '3,❑ 1 am a.homeowner doing all work . officers have exercised their 11.Q Plumbing repairs or additions myself [No workers'comp. right of exemption per MGL 12,Q Roof repairs insurance required j t c.152,§1(4),and we have no employees,[No workers' 13,❑Other COMP.insurance req fired.] "Any appfi ant thatohecksbox#1 riust also fit out the section below showing their workers'compensation policy information. T Aomeowam who submit this affidzyn md==g they are doing all work and then hire outside contrwtots must submt a new affidavit indicating such. t_—onnactors that check this box must attached as additional sheet showing the name of the sub•conb=tors and stair whether or not those m5ties have employees. if the sub•conttactons have=giloyees,they must provide their worlaxs'cornp.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: -7avdeis Policy#or Self-ins.Lic.#: 6 6-84 Z y - 1 -7Expiration Date. Job Site Address: CiWStztC(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 crirni al penalties of a Erne up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORE.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 Investieabons of the DIA for insurance coverage verification. 1 do hereb rtify wider fh gins•_ enalties of perjury that the information provided ahoy is tru acid correct Si store: Date: — Phone#: €1�cial use only. Do not write in this area,to be completed by city or town offcciaL City or Town: PermitUcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: i N. � 614/CERTIFICATE OF LIABILITY INSURANCE D/14/201IDDIY3 3 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Debi James NAME: FAX Leonard Insurance Agency, Inc PHONE AIC. (508)426-6921 A/C No:(508)420-5406 683 Main Street E-MAIL ADDRESS: genc debi@leonarda com y' Suite B INSURERS AFFORDING COVERAGE NAIC# Osterville MA 02655 INSURERA:Travelers Indemnity of America 25666 INSURED INSURER B Travelers Cas & Surety of IL 19046 Bourque Heating and Cooling Inc. INSURERC:Travelers Indemnity Co. 25658 B&L Equipment LLC INSURERD:Continental Casualty Company PO BOX 770 INSURERE: Marstons Mills MA 02648 INSURERF: COVERAGES CERTIFICATE NUMBERk4aster 2014 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR I POLICY NUMBER MMIDDIYYYY MM/DDIYYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE To RENTED 500,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence` $ A CLAIMS-MADE F OCCUR 6808B790617 /17/2013 /17/2014 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 POLICY PRO LOC $ AUTOMOBILE LIABILITY - COBINED SINGLE LIMIT EaMaccident $ 1,000,000 ANY AUTO BODILY INJURY(Per person) $ B ALL OWNED SCHEDULED A-BB791085-12-SEL /17/2013 /17/2014 AUTOS X AUTOS BODILY INJURY(Per accident) $ X X NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident Medical payments $ X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 3,000,000 C EXCESS LIAB CLAIMS-MADE AGGREGATE $ 3,000,000 DED I I RETENTION$ C UP-8B791269-12-42 /17/2013 /17/2014 - $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY I TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE YIN - E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N❑ NIA D 6S59UB-5B39530-A-13 05/17/2013 05/17/2014 (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Bourque Heating & Cooling Co. Inc. ACCORDANCE WITH THE POLICY PROVISIONS. B&L Equipment LLC PO BOX 770 AUTHORIZED REPRESENTATIVE Marstons Mills, MA 02648 Tina Boulos/LEOTBI ACORD 25(2010105) ©1988-2010 ACORD CORPORATION. All rights reserved. INSn25 r9mnnst m Thn Arr)Pr)nnmc and Innn me rnniefornrl mnrire of Arr)0r) 1 s� DRIUEt2'S - �� ,,LICENSE wa� � r a�iss� ` 9aENDf aaNluaeER i f[0511 2013 NONE s.�5�5..M2 3nn�za � � oqs � F =;ce �aaEs ass Nf 1 07QU s 44 CROOKED CARTWAY'z �f � '� MARSTONSINfLLS MA 02648 i008 5;DD OS13.2013:Rev07/52009: - CO MO NWEALTH OF MASSAC: USETTS SHEET METAL WORKERS AS-.'A MASTER UNRESTRICTED ENs To, ROBERT 6: .BOURQ.UE I4 CR0OKED CARTWAY � IARST0 US. MILLS MA 02648-I00 <6435 05/28l14 16351 i c 4 " Town of Barnstable „ Regulatory Services ` Was, Thomas F.Geiler,Director Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.maxs Office: 508-862-4038 Pax: 508-790-6230 Property Owner Must . Complete and Sign This Section If Usi=A Builder as Owner of the subject property hereby.authorize � `` S o�` act on my behalf, in a.0 r=tters relative to work authorized by this building peunit (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. sigdature of owner Signature of Applicant /� iv - Print Name Print Name � lot l3 Date Q:FORMS.OWNERPERNSSTONPOOLS TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION TOWN OF EIARP67ATtE I Map ` Parcel ��� Application # f. �2[Z-� Health Division 113l' R 'S 3 Date Issued Conservation Division Application Fee Planning Dept. r)T Permit Fee / Date Definitive Plan Approved by Planning Board 3 Historic - OKH _ Preservation/Hyannis fP_roject Street Address RC-,eNW00 b TO Ville age�—I �A (v l Owne` �I�l koc ke Address 6WfY-jV wop p T`elephone� �� � \.iNeAitRuest �, �f=, �i G� fwsk)Lau 0tj F&q 1 5—T Ram&jftt, NO P-epwiLb -* Square feet: 1 st floor: existing proposed 2nd floor: existing WO 'proposed Total new Zoning District Flood Plain Groundwater Overlay N0 ecTR40 e, KPWL 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 l Basement Type: � Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) __6*_ Basement Unfinished Area(sq.ft) A—W 4 Number of Baths: Full: existing 2 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 1"" New Existing wood/coal stove: ❑Yes I 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�`�cJP LAC/ ® � Telephone-Numbe_r '- Address ID Sam License-#- Home-Improvement Contractor-#----f Wor-ker_'s=Compensation;#_t, m ibaZ t ZD/2 AL'L CONSTRUCTION DEBRIS-RESUL-TINE-FROM"THIS PROJECT WILL BE TAKEN SIG GNATURE— — *, DATE_ q V 1, /✓ i FOR OFFICIAL USE ONLY a • - APPLICATION# DATE ISSUED ,. MAP/PARCEL NO. - ADDRESS VILLAGE OWNER i DATE OF INSPECTION: _._ FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL 4' PLUMBING: ROUGH FINAL c GAS: ROUGH FINAL' — FINAL BUILDING t DATE CLOSED OUT ASSOCIATION PLAN NO. i k ' 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 A licant Information Please Print Le M Name (Business/Organization/Individual): M�.P, �• ��J Address: �- 1 City/State/Zip: �; ��� Pf Phone#: A * on an employer?Check the appropriate box: Type of project(required): r 1. I am a employer with -2, 4. ❑ I am a general contractor and I employees(full and/or part-time). * have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on.the attached sheet. 7. ❑ Remodeling ship and have no employees These sb-contractors have g. 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.❑ 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.❑ 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, xContractors 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. �I Insurance Company Name: C. 1 9 21 Jo _Policy#.or Self-ins.Lic.#: ' bDDD �l2 Expiration Date: Job Site Address: 11_ ��,/ ��� City/State/Zip: .Attach a copy of the workers' compensation policy declaration page(showing the policy num er 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$1,50.0.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day-against the violator. Be advised that a copy of.this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby,certify der t pa' en ltie perjury that the information provided abovy is tlue and correct .:Signature: Date: Phone#: 7F/ 00� 5-W Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and .Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more ... of the foregoing engaged in a joint enterprise,.and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing'employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on,such dwelling house.' or on the grounds or.building appurtenant thereto shall not because of such employment be deemed to bean employer. MGL chapter.152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance.coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation-and,if. necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the 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,bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions; please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel, #617-727-4900 ext•406 or 1-877-NIASSAFE Fax# 617-727-7749 Revised 4-24-07 www.mass..gov/dia �h I 11 /16/2012 4 : 04 : 44 PM 8975 ® 02/02 ' r��l (MMlDD y) CERTIFICATE OF LIABILITY INSURANCE 6/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION•ONLY AID CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES HOT AFFIRMATIVELY OR NEGATIVELY AMEND, MC♦•EID 0%ALTER THE COVERAGE AFFO BY THE POLICIES BELOW. THIS CERTIFICATE Of INBURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSUMMIS), AUTHORISED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTART: If the certificate holder is an ADDITIONAL,INSURED, the policy(ies) Dust be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain icier may require an endorsement. A statement on this certificate does not colder rights to the certificate holder in lieu of' h andorsement(s). PRDDtMER CWTACRamT . Flaherty Insurance Agency Pu 51 ULU Street Unit 12 IA/C.R°•mot" E-ImIL Hanover, M 02339PROD E'; CUSTOMER IN. IRED®(s)AronDIRG CATERERS sue D - IesaRED MWER a:Associated Employers Insurance Company Christopher Alexander ICE: dba 14M Builders »IFUREM c: 10 School Street IESUM Do Hanover, Ili 02339 ffiD�e` INSUM Y: COVERAGES CERTIFICATE NUMBER: i REVISION NUMBER: THIS IS TO CBST>p4 THAT THE POLrCSNS OF INSURANCE LISTED HEID BSBN ISSUED ID THE INSURED NALNR MUSE FOR THE POLICY PERIOD IIDICATND. m4WI'ffi3WNDING ANY RE()U—e ' T'HER OR CORDITIOF OP ANY OA O'!1�D0001�1'WITH"SPEDP TO NHIM THIS CWTXr=ATE MY M ISSORD OR EAY P1RTAa, TMl.aSORAitS AFPOROM BY THE POLICIES IS SUBJECT To ALL TIM TYRES, NRCJASIONS AND CUSUMONS Or SUM POL=MS. Lrsrn SHONE IDLY HATE am RE CUM BY PAID CLAIES_ to POLICY NUISHE POLICY Err POLICY M LIMITS u' TTPN OF aSORANCN tnW/mn ,aNMTIR) GEffiAL LIABII,ITY EAQ ACCURNECE 4 r-i.. .6E.O.L LIABILITY AAUSSE Ta�TED I R®ISESIEa•oce°:<ewee) R ❑❑CIAIIB tube �Acc°a 1®� pwY m,e PezA°n) R t FMOEAL f OR YWRJWT $ oDERWL AGGIMID.TE GER'L AGGREGATE LIMIT APPLIES ER: POLICY 0—0- PQ➢DaETS-CAMP/OP lG6 R - S C=MV SINGLE LIMIT 8D'1�8II3��� - tea Ec°Sdewt! R nASY AUTO 1 - EOauI new W.psml R ❑ALL--AUTOS EISCHPDULED AUTOS DOILY 187111ITta+[—id-L) R •. PRDPm x DRUM i HIRED AUTOS lEs amlAmt) ❑DON-OtlQED API09 R EluxbRILLA LIAR D OCCUR RA®OCCImIIOCE B I �ESCESS LIMB ❑CLAIlB 11ADE D6l�BfiAD3 S ODSDUCTSELE R ❑ReTLNTIOE 9 � . WD�S CQIPNNSATION ® TotT ta¢TI p� AND MLAYHES=183I.TY . THE OR PROPRIET /PARTNERS/ R.L.RACE ACCIDAt S 100,000 A IXECIPTIVE OFFICERS ARE ❑ incl ® excl 5008600012012 : E.L.DISEASE ROLIETLnaf s 500,000 09/29/2012 09/29/2013 E.L.Dlseaa-EA E11OSEE a 100,000 taaSPrs DESCRIPTION or WHUTIAON an I"IfflaON: CHRISTOPHER ALEXANDER IS NOT COVERED BY THE WO RStCOMPENSATION POLICY. JOB - 62 CARLETON ST CERTIFICATE HOLDER CANCELLATION FTARAD EDWARD COLERAN SHOULD ANY OF THE ABOVE DESCRaND POLICas BE CANCAddD BAORt THE=ZRATTOB DATE THEREOF, NOTII:S WLL BS MELIYID® a ACODRDAHCN KITH TEE ETON ST Post PRovlsloM, MA 02382 FW 5614 i I Kt I�tc aass,i ifai tt v1" ',2t iii8er t�t bbli4.Zatetfy { ' Eioard of Building E ee ulatiQtts'and St darn C urietrstttpeiis;► i tt�t d. L cens ':.GSv09'M1 e ti'''r� p � \� Fi £ CEIRISTOP_AK1 E.A AND-L�E-.X- S 2 10 SCROO"TRBLT-1 - ;HANOVER MA 02339 ✓,�.,..JJ� tit`='`` E it fxratican � Commossioner i 01/17/2014 (/ &wmv4wve� Office of'Consumer Affairs and usiness Regulation 10 Park Plaza - Suite 5170. v Boston,Massachusetts 02116 Home Improvement Contracto . Registrat>on Registration;. T52975' Type DBA Expiration 10t23/2014 Tr11.232770 MMA BUILDERS : -- CHRISTOPHER ALEXANDER 10 SCHOOL.ST ,.. _. �. - . HANOVER, MA 02339 j �' Update Adel�ess and.return card.Mark reason for eharige, Address ❑ :Renewal`o Employment .� Lost.Cerd DPSCAt Co SOM-04/04-Gib1216 ; �fze �ro�ri��za.zwea/lj ✓h�aa.ac�iiiaeC s: Lieense,or"registration val'id`for mdividuf use only g Once of Consumer Affairs&B mess tiegulahoa` before the expiration date. if found return.to: err HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation Registration ,152975. Tie 10 Park Plaza-Suite 51701. Expiration 10/2312014 DBA Boston,-MA 02116 MNI�BUILDERS CHRISTOPHER ALEXANDER 10 SCHOOL ST - HANOVER,MA 02339 _' Undersecretary Not valid without signature Town of Barnstable t ► Regulatory Services snxiv&& E Thomas F.Geiler,Director Eo;A�"'�� Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us . Office: 508-8624038 Fax: 508-790-6230 Property Owner. Must Complete and Sign This Section If Using A Builder I, "► as Owner of the ero subject l P p rtY hereby authorize C6.17U S�Q11 _. / V��- � _ to act on mp behalf, in all matters relative to work authorized by this building permit 93 Ogmvwoob (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:FORM&OWNERPERMISSIONPOOLS 6=2 THE Town of Barnstable � Tol, .� Regulatory Services RARNSTABLE. : Thomas F.Geiler,Director 9�A '9. 'Building Division rED MA'I 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: t JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code ti The current exemption for"homeowners"was extended to include owner:-,occupied dwellings ofisix 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. t - . —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 erformed under the.build' ""p A mg_yerrrut. (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 w 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'l09.1.1 -Licensing of cons tructiofi 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 monsoon ��EEMMMMMM monsoon Rom 01 MOMENMEME OEM one son E ■EMMEMO■ MEM SEEM 0� MEMO an BEEME MEN SOMEONE so ME owns NONE SEEM ENEMIES ICE EEMS � OMENS 0I soon MONSOON 0 NEMESES ROMMESOMEONE HE 'MEN on MEN 0 soon soon 0 MEME - ■ so EMEMEMEME��1 « �� � �� MEME '■ on 'EMESSEENESS ME ME soI M, SEEM MEM O■ ME Ron WE MEN ■ _ ■E■ Sol M 0 In MEN so [ M MENOMON« MEN onI 00 mm, MEMMEMEM ONE ME MEMEME Ms «EMEMMEMMEMEM sm■ low on [ MEME EMEM !' IMMENSENESS IMMEN �MSSSSSSSSSSI MEMEMEME SEEN SEE NONE MEND Momm MEN on IMEMEM SEEMS SEEN® SEEM MEN so, MEN ME OMENS REM MEN M HOME ME son /MEM■M■■M■N MEN ME SEEMS SSSS■SSS■S MEN SEMI SS■SSSSSSS MEMEMEMEME MEN M SHE M ME � ■■■ i �. .� a � ■'■■ 'MEMO �■_ �■ ■ ■' ■■■ NUMA. was No ■ ■■ ;■II■■■■■■■ ■■■■■■ �■ ■■■ I ■ ■� ■■■ ■■� ■r ■■ ■■■ ■■ ■■■■M■■ ■■■■ ■■■■■■■■�■■ �■■■■■■� ■■■■� ■o, Ems" �0���■■���■■��■■■■�■�■■■il �■�■ ■■ �sligl ±■■i�� �■ _.-"■■� N M■� a ■0 0 �a 2 VC MMA on No ■lin�m,■� � ■ ■ Is not ■■' ON�i■■ � �■o MINIMESH&S�■■■ � � WE ■� �in 0 ■ ■' ■■ mmool� immossmsonsm MEN so S■l■■ ■ MEIN Ii��m■�■■m■■�� ■■■■■■■ s■!■■ i r IN MINE MEN ■■■■E MEMNON SEEM !■� ■■■■j M■N ■■■■ WMIMMIS■i no N■■■■■S ■ENSIMM■■ ■E■■ Eslosllos�! nom, �m■o■■om SOMEONE NEW ��■i■■■■■� 1�IN ■■■■■■n MIMES SENSES IN If ■■■■E■ O'010! ■ � %" Emmmmmmm E■■ti■■��� I1■■1�■■■ ■S■�■ I ■■■■ES m■■■■■■ ■it�■I■ [so ■■� I�■�■■EEE■■■■ NU■�■E■■ SEEMS, MEN MEIN SEEM 'MEMO 110111MUMM So Ilion smonsoloo 'SEINE,, 111EMSEMS ■■■ M � ■■■���■�OWI■�E■S �■t■ ME■■■■ MIMES ■■EMS,■■1I11010 ■■'�■'� �'■■■'■■■ ■■�■■ 01■■■■■ I1ss■■ons■�■lt■l MENNEN ■■I■ Il■EMMUM■II■EEE■N�■!■��001. SIEMENSMIMES ■ �. � ■■■■■■ IMME1,10 • ■E■NE■ ■■■■ 10 IN ■� ■'■■■■■■■� �'■■fib■■!■■■ ■ ■f ■E ■ ■■■±l1■�� ■■■■■■■ ■■�■■S■■■■■■■1 • -� �, �•. I �f I TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION ° V Map C�'� 'Parcel s Application # I �Q Health Division Date Issued Conservation Division Application ee • Planning Dept. Permit Fee �`'° 4�. Date Definitive Plan Approved by Planning Board Historic - OKH Preservation/Hyannis Project Street Address G-R-a-eV\wc,cw� � - Village �4 Q h►r< � TAOwner "V d- !'te -0--0- Address DID r i4-ti2*�'1''` Telephone Permit Request R-e h avl :VC k. %vVeJ,•-e.r c.v-ok, 'TU30 S Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 006, Construction Type Lot Size 11000 Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. J Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ArNo On Old King's Highway: ❑Yes ❑ No Basement Type: WrFull ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new . Half: existing f new ZS II Number of Bedrooms: 3: existing —new Total Room Count (not including baths): existing 7 new First Floor Room Count Heat Type and Fuel: ❑ Gas W Oil ❑ Electric ❑Other Central Air: ❑Yes Q No Fireplaces: Existing New Existing wood%coal stove: ❑Yes ❑ No Detached garage: ❑existing ❑ new size—Pool: ❑ existing ❑ new size._ Barn: O',existing. ?0 newt size_ Attached garage:Wexisting ❑ new size _Shed: ❑ existing ❑ new size _ Other: 4 Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# co Current Use `- Proposed-Use — APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name C 1 f p g�5 77.3 7� K IY1,i Telephone Number Address C2 1 CNA Pv� 5 � License # c 7 Co e-o 41 �(/12/,J Home Improvement Contractor# k S3 tg2 b Worker's Compensation # ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO emu' SIGNATU DATE FOR OFFICIAL USE ONLY APPLICATION# a DATE ISSUED 4 r MAP_/PARCEL NO. 1 ADDRESS VILLAGE OWNER t DATE OF INSPECTION: .f FOUNDATION FRAME s INSULATION: , r ` FIREPLACE ELECTRICAL: ROUGH FINAL ' PLUMBING: ROUGH FINAL GAS' ROUGH R=r - FINAL IFiINAL B_UILDING;!-!"•;-`'_ f ' 1 DATE CLOSED OUT ASSOCIATION PLAN NO. T L j y i ,S .> Th.e Cominonwecrlth of Massa chicsetts Department of lndustria[AccideWS Office of Investigations 60.0. Washington Street t Bostbn, MA 02111 At Lsy www:mass.gov/dia a Workers' Compensation Insurance Affidavit: Builders/Contractors/Ele triciansTBlumbers' Applicant Information 'Please Print I-,eRib 1-Y Name (Business/Organization/Individual): Ck A -r-_ V V,11, Address City/State/Zip:!NWo )Q N MA 0V5:01. Phone#: 51t'S _0hQ,--7`1 51 '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 - El"New construction ein to ees full and/of"-art-time .* have`hired the sub-contractors.. _ _ p y ( p ) listed on the attached sheet, 7. Remodeling 2. I am a sole proprietor-or partner- ship and have no employees These sub-contractors have g [] Demolition working for mein anycapacity. • employees- and d have wor kers' 9. ❑ Building addition No workers' comp. insurance comp.insurance required.] nd its ' 10.N Electrical repairs or additions- 5. [� We are a corporation a 3.❑ I am a homeowner doing all work officers have exercised their 11.1n Plumbing repairs or additions myself. [No workers comp. right of exemption per MGL 12:❑ insurance required.] Roof repairs c: 152,§1(4), and we have no q ] t �" 1.3.0 Other. employees. [No workers comp,insurance required.] *Any applicant that checks box 41 must also fill out the section"below showing their workcrs'compensation policy information. t Homeowners who sub ffid mit this aavirindicating they arc doing all work and then hire outside contractors must submit a new"affidavit indicating such„ #Contractors that check this box must attached an additional shect.showing the name of the sub-contractors and state whethcror 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' compyensation policy declaration page,(showing the policy-number and expiration date). Failure to secure coverage as required und6r.Section 25A'of MGI c. 152 can lead to the imposition of crimihal',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 thi statementmay be forwarded to the Office of Investigations of the DIA for insurance coverage verification. PI do hereby cer ' u der the pains.and penalties of perjury that the information provided above is trzee and correct. . Si nature: Phone#: C1(9 `7 [FOffuse only. Do not write in this.area, to be completed by city or town official* icial r-Town: Fermit/License# Issuing-Authority (circle one).: 1.Board of Health 2. Building Department 3• City/Town Clerk d.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: fnforma.txon and fnstr ctiODS Massachusetts General Laws chapter 152 requires all employers toinrihe's, workers' vice of another compensation for contracttheir plhyees. Pursuant to this statute, an employee is defined as .,. v y person express or implied, oral or written." her eht'ty, or any t An employer is defined as "an individual, partnership'udin c'thti n al representativesD '00 or of alegal eased employer Or the of the foregoing engaged in ajoini enterprise, and including g receiver or trustee of an individual, partnership, association or other legal ent ty, employing employees. However the i owner of a dwelling house.haying not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, constniction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be decmed to be an employer." MGL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance w or a license or permit to operate a business or to construct buildings in the commonealth for any renewal of ptable evidence of compliance with the insurance coverage required." applicant who li has not produced acce Additionally,MOL chapter 152, §25C(7) states "Neither the conunonwealth nor any of its political subdivisions shall of compliance with the insurance enter'into any contract for the perfofriiance of public.-work until acceptable evidence 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), addresses)and phone number(s)along with their cerlificate(s) of insurance, Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP)with no employees other than the insurance. If an LLC or LLP does have members or partners,arc not required to carry workers' compensation employees,ie policy is required. Be advised that this affidavit me submitted ub itt d to the the affidavit ntThe affidavit of should Accidents for confirmation of insurance coverage. Also be sure to g m 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' please call the Department at the number listed beloW..Self instu-ed companies should enter their compensation policy, self-insurance license number on the appropriate line. City or Town Officials affidavit is complete and printed legibly, The Department has provided a space.at the bottom Please be sure that the 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 permiUlicense number which will be used as a.reference number. In addition, an applicant Thai muss submit multiple permiUlicense applications in any given year, need only submit one affdavit indicating current Dr policy information (if necessary)and under"Job Site Address" the applicant should write"all locations in town)."A copy of the affidavit that has been officially stamped or marked by the city Dr town may be provided to the affidavit must be filed out each applicant as proof Lhat a valid affidavit is on file for future permits or licenses. A new er or citizen is obtaining a license or permit not related to any business or commercial venture year. Where a home own (i.e. a dog license of permit to burn leaves etc•) said person is NOT required to complete this affidavit. ur cooperation and should you have any questions, The Office of loves►igations wou like o �h-�n-kyw���� r�`O r • please do not hesitate to give us a call, The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of In-vestigatiDns 600 Washington Street Boston, MA 02111 Tel. 4 617-727-4900 ext 406'or l-877-MASSAFE Fax # 617-727-7749 Revised 4-24-07 www.mass.gov/dia 'fKEr, . Town of Barnstable ' Regulatory Services • sixxsrest.� f - Thomas F. Geiler,Director �Eo Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,NIA 02601 :www.town.b arnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete_and Sign This. Section If Using A Builder I, )'Y)A'9 Mt.-e� as Owner of the subject.property hereby authorize. Ig ^� to act on my behalf, in all matters relative to work autho rized by this building perirmit application for (Address of Job) t . 7 /9 iv Sig afore of Owner nate . Print`Name If Property Owner is applying for.permit please complete -the- Homeowners License Exemption Form on the reverse.side": , Q:FORMS:O WNERPERMISSION �ofi�ray Town of Barnstable o Regulatoty Services saxrvst�st� Thomas F. Geiler,Director Building Division orED � Tom Perry,Building Commissioner 200 Mairi.Street, Hyannis,MA.02601. vt wmtown.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE`EXEMPTION Please Print DATE: JOB LOCATION: number street village- "HOMEOWNER!': name hDTM phone# work phone# CURRENT MAILING ADDRESS: city/town states zip code T1te current exemption for"homeowners"was extended to include owner-occupied dwellinu 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 tt supervisor. DEFINITION-OF HOMEOWNER` Persons)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 constrgcts more than one home in a two-year period shall not be considered a homeowner. Such "homeowner"shall submit to the Building Of5cial on a.form acceptable to the Building Official, that helshe 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 .Tba Code states that "Any bomeowner performing work for which a building permit is rcquimd shall be exempt from the provisions of this section.(Sectivn 1D9.1.1 -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 rxcmption are unawart that they are assuming the responsibilities of a supervisor(see Appendix Q, Rules&Re9blations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often rtsults 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 responnbilitics,many communities require,as part of the permit application, that the homcovmer certify that heishe understands the responnbilibrs 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:homccxcmpt , ..: L�,Nayrllmetlt ofAu etc ul i, Rrft-ttl , •.Lice p@F.�1�gOICeFlS�C h: �'" �•, nse`,CS 76647 Restricted to... 00 41 t . CHRISTOP ,� � HER A=KIRITSY ! 21 OXFORD'ST NORTH AUBURN, MA 01501`r Commusutner' Expiration: 7/23/2011 Tr#: 1463 �itee _ rI� it 41ti+ �U ,,,� '"T' -� ioiss anu ttuchws 1�t r #y tc� sorrrgfstr�teh .n'it•fcr mdAlicl vse on'y NO.iYiE IMPROVEMENT.QONTRACTDR / - Registrao q,. .4- fly�x(ilr�ho. :dlttc.} (f found r Etur #v • - - ?ieou:..tions aril SfanRiards P 53( r[ dm' r o e As i ati .n '2/19/2010 Tr# 279'15' �r 1` M Place Rm 1301 Bn hb ul: p n '� �r� 2t08 x I t�tdual . .; +' ems` ur T a.U - CHRISTO.PHER A'.K111TY `.+ CHRISTOPHER iFCPITSY AUBURN MA 01501 AtlmmtstratAr+,rt i�''0 - >y valid without Mgna re I s 1 l J iJ tu Z. . - e . a 7 tl F 'Tu + s ♦ V Town of Barnstable *frmi `� � _t Expires 6 montl rom iss a date Y • Regulatory Services Fee Thomas F.Geiler,Director. Building Division Tom Perry,'CBO, Building Commissioner' 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us. Office: 508-862-4038 Fax: 5,08-790-6230 EXPRESS PERMIT APPLICATION RESIDENTIAL ONLY' yip Not Valid without Red X-Press Imprint Map/parcel Number Property Address C7lcEP�(,l�Q4l1. ✓�i. T ,t/.(J l /�/9 L d0��l [R'kesidential Value of Work ao0 Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address' 8mk F 6<e� P/V LJVdl !/O �tJ� Contractor's Name /• Telephone Number Home Improvement Contractor License#(if applicable) - Construction Supervisor's License#(if applicable) . 4PRESS PERMIT. ❑Workman's Compensation Insurance Check one: MAY 2'.G 2010 El I am a sole proprietor LzJ"I the Homeowner ' °TOUUN`®F BARNSTABL ❑ I have Worker's Compensation Insurance . Insurance Company Name '+k r Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. . Permit Request(check box) Re-roof(stripping old shingles)All construction debris will,be taken to ❑Re-roof(not stripping. Going over existing layers of roofl e-side #of doors Replacement Windows/doors/sliders.U-Value (maximum.44)#of windows *Where required: Issuance of this permit does not exempt compliance with'other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors License is required. r i SIGNATUREc - C:\Users\decollik\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\4STGU5QO�E)PRESS.doc Revised 090809 77te Conrnrontivalth of Massachusetts Department of Indrrstraal Accidents -- QTwe of 1westigations 600 Washington_Street Boston,AIA 02111; ipwrl?nrass.govldia Workers' Compensation Insurance Affidavit: Builders/Contractors Electricians/Plumbers Applicant Information Please Print Le 'b Name(Rttssiness/Orgmization/Individual): Address: �f �1Q2PwGJ s�� City/Stat&Zip: i4�N/S /� 0at bv/ Phone 4: ORO Are you an employer"Check the appropriate box: T of project r ' 4. I arm a general co�ntiactor and I 3'Fe� P J ( ����= 1.❑I am a employer with ❑ g b. New construction employees(full and/or part-time)_* have hired the sub-contractors 2.❑ I an a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have 8_ ❑Demolition } working for me.in any capacity. employees and have workers 9. �]3uilding addition. [No worl�ers'comp_insurance cow'ens�ssance.T 10.❑Electrical ors or additions r d_] 5. ❑.We are a corporation and its 3_ am a homeowner doing all work officers have exercised their I LF❑Plumbing repairs or additions' myself [No workers'comp., right of exemption per MGL 12.Dk6 of repaics insurance require&]-o c. 152,§1(4),and we have no to [No BE other e mp Yam-LN , comp.insurance required_] ;Any applicant awt checks bw#1 in=also fill am the section below showing diek waikers'compensation policy information_ Homeowams who submit this affidavit indicating they we doing all work and theft hire outside contractors Est submit anew affidavit indicating sub- ' TConnactors that:chack this boo mat attached an additional sheet showing the name of the sub-caanacmis and state whether or not those entities have . employees. If the sorb-canuactors have employees,they ttttast pmride their workers'comp.policy number. ' I am an employer that is providing workers'conlpensean insuran.a for my evTWeex,Below is thepoticy and job.site inf0ronati016 Insurance Company Name: Policy#or Ssl ins.Lie.#: tpiration Date. Job Site Address: City/StatelZip: 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 c6versge verification- I do hereby certify under thapa�i►isandpenabies ofperjury that the information proodded above is true and correct Sionture: T "w*'"vL" Date- Phone#: S0�`L9117- Lq0�0 Offldal rose only. Do not write in this area,to be completed by city or 16sm official City or Town: Permit/License Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.CitylTown Clerk 4.Electrical Inspector S.Plumbing Inspector B.Other Contact Person: Phone#: i �1 Town of Barnstable Regulatory Services Thomas F.Geiler,Director • Building Division Tom Perry,Building Commissioner,; 200 Main Street, Hyannis,MA 02601 :.. www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION qq.- Please Print DATE:' 64efA)icj&vd Ale_ JOB LOCATION: number street vill e _ "HOMEOWNER": < name �y home phone# work phone# > CURRENT MAILING ADDRESS: / ,e4k 4kJ , city/town 9 ' state L 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 fie/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 Qerformed 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. x: 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. Sign�at eofIlomeowner 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 1091.1-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. a 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 aSupervisor. On the last page of this issue is a form currently used,byseveral towns.'You Maycare t amend and adopt such a form/certification for use in your community. C:\Users\decollikWppData\Local\MicrosoMWindows\Temporary Internet Files\Content.Ougook\4STGU5QO\EXPRESS.doc Revised 090809 t 4 z� tAk ITc H F- I\\ S KE DETECTORS REVIEWED F-5 BARNSTABLE BUILD NG DEPT. DATE T FIRE DEPARTMENT DATE OOTH SIGOTURES ARE REQUIRED FOR PERM Tiwi _ AA3- - LA v � ., .� � r _ _{ 1+�, V/ C -17 Oda S � YG Woo 0 { y L^ i71 _IA I W s s ! i i ......... _._ _ - J r UD 7 ..-_ _- ... ... -_ ._.............. _. _ .. ..--. _ -. .. Q 1pt I F -2 t :