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0072 GROVE STREET
y 'I (� h' y� + J s ,i ,1 �; __ _ �r i i �'®1 (�' {i -- �� s ,. II � °� �� -- � IKE ?Y3 Application Number...... .... ........................ MIRWN ABM # BUILDING DEPT. MASS. Permit Fee......... S..............Zoning District.......................` i639. ♦� MAY 0 7 2020 Total Fee Paid.......... SCANNED............................. ...... TOWN OF BARNSTAB �l7420 TOWN OF BARNSTABLE Permit Approval by.... .:.............on.. .�.�:.. ...... BUILDING PERMIT Map.......30.�..... .........'...Parcel........C?> - ..�..............:.....: APPLICATION Section 1 — Owner's Information and Project Location Project Address -4 2 G 7,0 ye, Village oa 05 '' � L Owners Name M 0 'ZO i�V 1. C �� 22 jP 2'v E ; A E Owners Legal Address a cC 0 o 1-ccl-e J o t c City L/U- q 2�4 IQ 6 ee. State /t4 e Zip 0 2 6 6 P Owners Cell # t' S S n0 E-mail • nN u ` Af 6 f1 C Gores Section 2 —Use of Structure Use Group ❑ Commercial Structure over 35,000 cubic feet 0 Commercial Structure under 35,000 cubic feet Single/Two Family Dwelling Section 3 - Type of Permit ❑ New Construction ❑ Move/Relocate ❑ Accessory Structure ❑ Change of use ❑ Demo/(entire structure) ❑ Finish Basement ❑ Family/Amnesty ® Fire Alarm Rebuild ❑ Deck Apartment Sprinkler System ❑ Addition ❑ Retaining Wall ❑ Solar ❑ Renovation ❑ Pool ❑ Foundation Only Other— Specify Section 4 - Work Description n v�4-&z .o 1/, di �eC.fdzg , Lt P 'Z4 de i vVS IQ- P a quo®-z, Last updated: 1/31/2020 , Application Number...............................................:.... Section 5—Detail Cost of Proposed;Construction 10'0 V Square Footage of Project Age of Structure Dig Safe Number # Of Bedrooms Existing 3 Total# Of Bedrooms (proposed) S 110 MPH Wind Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist ❑ Design Section 6— Project Specifics ❑ Wiring ❑ Oil Tank Storage Smoke Detectors . g ❑ Plumbing ❑ Gas ❑ Fire Suppression ❑ Heating System ❑ Masonry Chimney ❑ Add/relocate bedroom Water Supply Public ❑ Private Sewage Disposal ❑ Municipal ❑ On Site Historic District ❑ Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility: S IZ_ X G 0 I am using a crane ❑ Yes 0 No Section 7— Flood Zone Flood Zone Designation Within or adjacent to a wetland, coastal bank? Yes ❑ No Section 8 —Zoning Information Zoning District Proposed Use Lot Area Sq. Ft. Total Frontage Percentage of Lot Coverage #of Dwelling Units (on site) Setbacks Front Yard Required Proposed Rear Yard Required Proposed Side Yard Required Proposed k Has this property had relief from the Zoning Board in the past? ❑ Yes; ❑ No. - k f oaf Last updated: 1/31/2020 . CIA The Commonwealth of Massachuseta Department of IndustrkdAccidents Office of Investigations 600 Washington Street Boston,MA 02111 wwlw.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / > Please Print Legibly Name(Business/Organization/Individual):,. �� o'I",-e 0 V Q. �.��Q'Z�2v�SCE L I C Address: 2 G z o v e S City/State/Zip: Q o 2 re 0 Phone M &t 357 S- J 0 0,6 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. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet: 7. ❑Remodeling ship and have no employees These sub-contractors have g• [Z Demolition working for me in an aci employees and have workers' • � Y capacity. [No workers'comp.insurance comp.msurance.t 9. ❑Building addition 5. ❑ We are a corporation and its 10.El Electrical repairs or additions required.] officers have exercised their 11. Plumb repairs 3.�I am a homeowner doing all work h id ❑ � eP •rs 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 infom�ation t Homeowners who submit this aT3davit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers compensation insurance for my employees. Below is the policy andjob site information. Insurance Company Name: Policy#or Self--ins.Lie.#: Expiration Date: 3 '/2 O 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 certify under the pains andpenahles ofperjury that the information provided above is true and correct Si mature Date: le 0 Phone#: 6 / " 1 S'5-` 5006 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 M n 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 constrict 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 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 021.11 Tel.#617-727-4900 ext 406 or 1-877-MASSAM Revised 4-24-07 Fax#617-727-7749 www:maw.gov/dia of l� v (APOlar-cM je0,92 rC -►k n4 oz 70�Z 'p02 vA W wOJw ,.. IAtt H 0�O(.✓ li S�� ✓ V\ Poaa R°� m 3 2 sI� q DETECTORS REVIEWED SLPOKEzo �, pooh -/q_ao 3 BARNSTABLE BUILDING DEPT. DATE Do°Z IDo°Z FIRE DEPARTMENT DATE BOTH SIGNATURES ARE REQUIRED FOR PERMITTING 016- � •�o� . a9�ow �ooz Cos) J 0 N o � � CID 3 e 5 C� C 2 %A of eo�9 z Application Number........................................... Section 9—Construction Supervisor Name Telephone Number Address City State Zip License Number License Type Expiration Date Contractors Email Cell # I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 : CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your license. Signature Date Section 10—Home Improvement Contractor Name Telephone Number Address City State Zip Registration Number Expiration Date I understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your H.I.C... E Signature Date Section I I —Home Owners License Exemption Home Owners Name: /L4 o Z o ?-0 V 2 eZri2 i S e L L G Telephone Number 6/1 - 5 S 5 —3 o 10 6 Cell or Work Number 6/7, 5 SS, 50 0,6 I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date '/z ,2-0 APPLICANT SIGNATURE Signature Date Print Name A o Zo a0 V- . YL t4e=tZz7 se L 6 C Telephone Number a/-1 - S 5r j o06 E-mail permit to: 0 G, 1t4 67- C:01,4-x Last updated: 1/31/2020 Section 12 — Department Sign-Offs Health Department ❑ Zoning Board (if required) ❑ Historic District ❑ Site Plan Review(if required) ❑ Fire Department ❑ Conservation ❑ For commercial work,please take your plans directly to the fire department for approvak Section 13 — Owner's Authorization 'W;L o � , as Owner of the subject property hereby authorize Z o v /3 K to act on my behalf, in all matters relative to work author] ed by this building permit application for: f 72- Cave H vx A/Ut 0Z 6rd/ (Address of job) Si ature of Owner date , TI,i z ; N .o zo v V e Print Name i 1 Last updated: 1/31/2020 1 r r Town of Barnstable - Building RAPOWABM Post This @a'rd�So That rt rs�Visible From�the Street :Approved<P,Ian�s Must be�Reta�ned�on Joband�thrs Card�Must;be Kept , XAMPosted,Until�Final In§pection HasnBeen Made ��s � � y£ s.� Termit �,,,�a Where a�Certrficate�of Occupancy;s Requ�ired,,swch 8uildmg.=shall Not tie Occupied un#�I a�Final Inspectionhas been�made Permit No. B-20-793 Applicant Name: MOROZOVA ENTERPRISE LLC Approvals Date Issued: 06/11/2020 Current Use: Structure Permit Type: Building-Restore to Single Family Expiration Date: 12/11/2020 Foundation: Location: 72 GROVE STREET, HYANNIS Map/Lot: 309-255 Zoning District: RB Sheathing: ,' Owner on Record: MOROZOVA ENTERPRISE LLC 61 ' •. Contractor Name,, Framing: 1 Address: 2400 MEETINGHOUSE WAY Cont"ractor License` 2 WEST;BARNSTABLE, MA 02668 ; � � � Est. Protect Cost: $ 1,000.00 Chimney: m the Permit Fee: $85.00 Description: voluntary smoke detectors upgrade,install a doorfro ex , family apartment to the main house making rt a�sirigle family home. Fee Paid ' $85.00 Insulation: Date 6/11/2020 Final: Project Review Req: No zoning determatation required per Bnan email 5 20 2020 , Plumbing/Gas x Rough Plumbing: x Building Official f; Final Plumbing: This permit shall be deemed abandoned and invalid unless the work author ed bythls permit is commenced within sixmonthsafter,,issuance. All work authorized by this permit shall conform to the approved appl1cationand theapproved construction document sfo�whichthis permit has been granted. Rough Gas: All construction,alterations and changes of use of any building and structures" hall,tie in compliance with the local zon�ing'by-lawsand,codes.This permit shall be displayed in a location clearly visible from access street o`r roatl and shall be maintained open for publicrospe n for the entire duration of the Final Gas: work until the completion of the same. t' M' J , mr Electrical The Certificate of Occupancy will not be issued until all applicable signatures by'theBuilding andireOfficials are.providedonth is permit. Minimum of Five Call Inspections Required for All Construction Work ' £ s Service: 1.Foundation or Footing g 2.SheathingInspection s Rou h: 3.All Fireplaces must be inspected at the throat level before firest flu0iriing is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final: 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Work shall not proceed until the Inspector has approved the various stages of construction. Health "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Final: Building plans are to be available on site Fire Department All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final: C-o c ova � o P- 'T � L) G— v9 (RA-7—to � fisijs E a�.at T9 �i 1, s• 1I1M1�� �� � � � � � 1/1 '.re IR •1. � IrM! M� � M� i ir• w ,,��[ ^w� fir• ;, 1+.: i ._ .r � .,� ••� .5 .�' i K � ,Y.k $�* n cif y _ �. .V p _.ud �5og ) �1 -0�45 secs eV-1 c��„'� S, MA 02601 d Floor Third Floor Fourth Floor Patio ent -10 P.M. 55 erior 80 that the premise, structure or portion thereof as herein specified has been .ramed behind clear glass and\or laminated and posted in a conspicuous place ling with the contents of the certificate is strictly prohibited pal Robert McKechnie Date of issioner Local Inspector Inspection 12/07/2018 nicipal Date of issioner Issuance 9/20/2019 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION - i Map Parcel . Permit# � 3 Health Division CqD-5 C/)66 Date Issued 0� _ Conservation Division I ak r Fee b f, ;0 =Tax Collector EXISTING SEPTIC SYSTEM Application Fee Treasurer !-IMITED TO 3 0 OF BEDROOMS Planning Dept. Checked in By Date Definitive Plan Approved by Planning Board Approved By Historic-OKH Preservation/Hyannis Project Street Address :I la �0 1WS n Village f4 U 0 V1V►l Owner E64n�c,lQ Rm S 4 n Address Telephone Permit Request ff I` i Square feet: 1 st floor: existing proposed ' 2nd floor: existing proposed ToAl new'n z Valuations Zoning District Flood Plaint Grou water QZrlay- Construction Type ' Lot Size % cu r Q . Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family C- Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: Cl Yes 21"'No On Old King's Highway: ❑Yes �o Basement Type: ❑Full ❑Crawl ❑Walkout �'_rOther rLL lOaAe y�—� c�Kr�, ,r ono M 0- Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new . Half:existing new Number of Bedrooms: existing Total Room Count(not including baths): existing J�-- new( First Floor Room Count %7:q, Heat Type and Fuel: CdGas ❑Oil ❑.Electric ❑Other I Central Air: ❑Yes Flo Fireplaces: Existing ® New ® Existing wood/coal stove: O Yes Ero Detached garage: Eexisting ❑new size Pool:❑existing ❑new size Barn:0 existing Cl new size Attached garage:❑existing ❑new size Shed:0 existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ZrNo If yes, site plan review# Current Use Proposed Use w BUILDER INFORMATION flName Al\6 Telephone Number s �� � U0 --�. Address A�,m1-�_�� License# § t AA 1 o26 Q( Home Improvement Contractor# 1 _ Worker's Compensation.# v ALL CONSTRUCTION D BRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE��'Zj�� DAT k�j®/ i r - FOR OFFICIAL USE ONLY PERMIT NO. • DATE ISSUED MAP/PARCEL NO. ti ; ADDRESS- VILLAGE t •r- OWNER r DATE OF.INSPECTION: ' FOUNDATION j cs FRAME = 91 1 < INSULATION !'! FIREPLACE r C.j t.3 ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL iv • GAS: ROUGH FINAL FINAL BUILDING _ DATE CLOSED OUT ASSOCIATION PLAN NO. L t I � Bk i 20463 PO 198 -ID79651 1 1-10-2005 a 12 = 59P Town of Barnstable �FTHE ��� �� �� " Regulatory Services anxNsznate Thomas F.Geiler,Director 'e;� �� Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-7�-6230 AGREEMENT FOR FAMILY APARTMENT I(We), the undersigned, being the owner(s) of property situated at 72 GROVE STREET in Bte-►kruS, MA, holding title under a deed recorded with the Barnstable County Registry of Deeds or Barns able County District Registry of the Land Court in Book Q 23 ? , Page 70 , or as Document No. being shown on Assessors' Map 309 as Parcel 255, hereby agree, certify, warrant and' represent to the Town of Barnstable that the accessory attached apartment,which contains living quarters, is intended for use as a family apartment,for year-round occupancy. The intended and authorized use is for EDWARD AUSTIN, BROTHER OF OWNER PATRICIA AUSTIN associated with the residential use on the same premises. This unit shall be used for a"Family Apartment" (as defined in Zoning Ordinances) which would require compliance with the Family Apartment Rules and Regulations. This unit shall not be rented as an apartment or as a single room, or in any fashion,which rental would be a violation of the Town of Barnstable's rules,regulations,and zoning ordinances. Prior to occupancy of this unit, affidavits reciting the names of occupants are to be recorded with the building department. This agreement shall be updated whenever a change occurs or every calendar year. This Agreement shall be duly recorded or filed at the Barnstable County Registry of Deeds/Land Court for the purpose of alerting future owners of the property of this binding Agreement concerning the use of the property as herein stated. The consideration for this Agreement is the issuance of a building permit and/or certificate of occupancy by the Town of Barnstable Building Department. WITNESS our hands and seals this / day of�V ;`l� 200 ° _P TOWN OF BARNSTABLE R(S� dd��" A - - (L �P("A( 1 ui d�inAConmisVSACHUSETT THE COMMONWEALTH OF BARNSTABLE COUNTY,SS' Date -Then personally appeared the above-named (owner) �'I/j 1Au- Y� and made oath as to the truth of the foregoing instrument,before me. Notary Public CT - BARNSTABLE COUNTY MARY C. GMFFITHS REGISTRY OF DEEDS My Commission E pires:A TRUE Copy,ATTEST Notary Public �' MY Commission Expires Feb. 24, 2066 JOHN F.MEAD REGISTER Q vvord/aacessoryagreement BARNSTABLE REGISTRY OF DEEDS oFt�r� Town of Barnstable "o Regulatory Services BARNSTABLE, Thomas F.Geiler,Director 94, MASS. & Building Division AjED N1P•�A Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 AGREEMENT FOR FAMILY APARTMENT I(We), the undersigned, being the owner(s) of property situated at 72 GROVE STREET in CENTERVILLE, MA, holding title under a deed recorded with the Barnstable County Registry of Deeds or Barnstable County District Registry of the Land Court in Book , Page , or as Document No. being shown on Assessors' Map 309 as Parcel 255, hereby agree, certify, warrant and represent to the Town of Barnstable that the accessory attached apartment,which contains living quarters, is intended for use as a family apartment,for year-round occupancy. The intended and authorized use is for EDWARD AUSTIN, BROTHER OF OWNER PATRICIA AUSTIN associated with the residential use on the same premises. This unit shall be used for a"Family Apartment" (as defined in Zoning Ordinances) which would require compliance with the Family Apartment Rules and Regulations. This unit shall not be rented as an apartment or as a single room, or in any fashion,which rental would be a violation of the Town of Barnstable's rules,regulations,and zoning ordinances. Prior to occupancy of this unit, affidavits reciting the names of occupants are to be recorded with the building department. This agreement shall be updated whenever a change occurs or every calendar year. This Agreement shall be duly recorded or filed at the Barnstable County Registry of Deeds/Land Court for the purpose of alerting future owners of the property of this binding Agreement concerning the use of the property as herein stated. . The consideration for this Agreement is the issuance of a building permit and/or certificate of occupancy by the Town of Barnstable Building Department. WITNESS our hands and seals this day of 200 — TOWN OF BARNSTABLE OWNER(S) By: w din CommissioneVSACHUSETT THE COMMONWEALTH OF BARNSTABLE COUNTY,SS Date Then personally appeared the above-named (owner), and made oath as to the truth of the foregoing instrument,before me. Notary Public My Commission Expires: Q:word/accessoryagreement I d` 1 16G.11"119 Uf&r eats" of lrlassuCn"'Ne"s Department of Industrial Accidents Office.of Investigations ' d 600 Washington Street y` Boston,MA 02111 www mas&gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): "CZl- Address: City/State/Zip: . UV �hF` one#: Q 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 ❑New const<uction 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 working for mein any capacity. workers' comp.insurance. 9 ['Building addition [No workers' comp. insurance 5• ❑ We are a corporation and its 10.❑ Electrical repairs or.additions � r�luir 3. ed.] officers have exercised their eP LJI am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself;[No workers' comp. c. 152,§1(4), and we have no 12.0 Roof repairs insurance required.]t employees. [No workersx 13 ❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information: .a t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such tContractors that check this box.must attached ea additional sheet showing the name of the sub-contractors and their workers'comp,policy information. lam 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 form of a STOP WORK ORDER and a fine of .p 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 certify u er a pains and penal'es a •ury that the information provided above is true and correct: Signature: i Date: 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#• 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." « association,porporation or other legal entity,or any two or more An employer is defined as an individual,:partnership, 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 workvn such dwelling house thereto shall not because of such employment be deemed to be an employer." or on the grounds or building appurtenant 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 1 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 J r partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have embers o , m P employees, to 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 Indust rial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' call the Department at the number listed below, Self-insured companies should enter their compensation policy,please ep � self-insurance license number on the appropriate line. City or Town Officials . e be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom Pleas g Y g applicant of the affidavit for you to fill out in the event the Office of Investi ations has to contact you regarding the app ber which will be used as a reference number. In addition, an applicant Please be sure to fill in the pernnit/license num that must submit multiple permittlicense 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 't not related to an business or commercial venture or permit a license Y year.Where a home owner or citizen is obtaining p said son is NOT required to complete this affidavit (i.e. a dog license or permit to burn leaves etc.) person er 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 r Office of Investigations 600.Washington Street- . Boston,MA 02111: Tel.#617-727-4900 ext 406 or-1-877-MASSAFE Fax#617-7274749 Revised 5-26-05 www.mass.gov/dia i Town of Barnstable �P��tNEO� Regulatory Services y Thomas F.Geiler,Director MAM II yg, i Building Division sets "Teo►+�►'�" Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town barnstable.ma.us Fax: 508-790-6230 fide: 508-862-4038 HOMEOWNER LICENSE EXEMPTION ' Please Print L j DI' ---4 ATE c JOB LOCATION• street village number i�t E V1 "HOMEOWNER'. , home phone# work pbone# name CURRENT MAzNG ADDRESS:- city/tom 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 re onstble for all such work verformed tinder the building rermit. (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 Qts. ' 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 hates 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,thaf such Homeowner shall act as supervisor." Many homeowners who use this exemption are unaware that they are assuring the responsibilities of a supervisor(see Appendix Q, Rules a Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problem 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 responsi3Je. 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 fora ccrtifieation for use in your community. A•FnrmrhmneeXCGIDL - 70 CMR Appe�din J ' TahleJ5=b(eontioaed) . prnerlptive Packages for due and TnaFamlllr ResidentW SnOdimw Heated with Fossil Fuels • MAJ Mum MIIViA'1lJ1Vi Wall Floor .Baseaect Slab Fi 81�1�B Glazing Glazing Cci g wall perimeter Equipmcnt Mciency, Aresi(�•) L1•valuer R-valuW R value &value° R value R-valua Package • ffs5701 to 6500 Seating Degree D Normml 12% 0.+40 38 13 19 10 Normal12% U2 30 _19 19 10 12%' 040 38 13 19 10 NIA �zi _——••T— :---13J—..:036____ 38 13 Z5 NIA 10 0 _ —Na=al- - --- ' 19 19 '� y .46 38 ::NIA 85AFE1E 38 13. 25 NIA b 83 AFUE 0m.. 30 i9 19 10 ° .1V. 25 NIA NIA Normal. X 032 ' 38 Normal Y 12% ' 0.42• 38 19 25 NIA NIA Z .' - 18% 0.42 38 13 19 10 8 90 6 90 ARE AA •• 18% 0.50 30 19 19 10 E 1.-ADDRESS OF PROPERTY; 2. SQUARE FOOTAGE OF ALL EXTERIOR WALLS:. 3. SQUARE FOOTAGE OF ALL'OtAZING: 4. %GLAZING AREA(#3 DIVIDED BY 92): ® � 5. SELECT PACKAGE(Q•-AA•see chart above): NOTE: OTHER MORE INVOLVED METHODS OF DETERMINING ENERGY REQUIREMENTS ARE AVAILABLE, ASK US FOR THIS INFORMATION. BUILDING INSPECTOR APPROVAL: NO: q-forms-1�84303a , 780 CM&Appendix J Footnotes to Table A2.1b: assemblies mcludin sliding-glass doors, skylights, and + Glazing area is the ratio of the area of the glazing (� g basement windows if located in walls that enclose conditioned space,but excluding opaque doors)'to the gross wall area,expressed w a percentage.Up to 1%of the total glazing area may be excluded from the U-value requirement. For example,3 J:e of decorative glass may be excluded from a building design with 300 fl of glazing area. i After January 1, 1999, glazing U-values must be tested and documented by the manufacturer In accordance with the National Fenestration Rating Council (NFRC) test procedure, or taken from Table J1.5.3.a. U-values are for whole units: center-of-glass U=values cannot be used. The.ceiling•R values do not assume a raised or oversized truss constrLiction. If the insulation achieves the full insulation thickness over the exterior walls without compression, R 30 insulation may:be substituted for R 38 ,_.A._ . insulation and R-3'8 insu7afion riiay be'sttb itiited10eR=49 insulation: CeilingR xalues-represent the sumo cavity— • --• insulation plus insulating sheathing(trused). For veatil tid ceilings, insulating sheathing must.be.placed between . the conditioned space and the ventilated portion of the roof. •'use Do not include' 'Wall R-values represent the sum.of the wall cavity insulation plus insulating sheathiag'( d)• • exterior siding, structural sheathing,.and interior drywall For example,an R 19 regnirernent could be met EITIiER by R-19 cavity insulation OR R-13 cavity insulation plus R 6 insulating sheathing. Will requirements apply to wood-frame or mass(concrete,masonry,log)wall constructions,but do not apply to metal-frame construction. The floor requirements apply to floors over unconditioned spaces(such as unconditioned crawlspaces;basements, or garages).Floors over outside air must meet the ceiling requirements. 6 The entire opaque portion of any individual basement wall with an average depth less than 50%below grade must meet the same RRvalue requirement as above-grade walls' Windows and sliding glass ,doors.of conditioned. basements must be included with the other glazing. Basement doors must meet,the door.U-value requirement described in Note b. The R-value requirements are for unheated slabs.Add an additional R-2 for heated slabs. If the building utilizes elgetric resistance heating use compliance approach 3;4,'or 5.•'If you plan to install more than one piece of heating equipment or more than one piece of cooling equipment,the egdiprrient with the lowest efficiency must meet.or exceed the efficiency required by the selected package... For Heating Degree Day requirements of the closest city or town see Table J5.2.1a NOTES: a) Glazing areas and•U-values are maximum acceptable levels.Insulation R-values are minimum acceptable-levels. R-value requirements are for insulation only and do not include structural components. b)Opaque doors in the building envelope must have a U-value no greater than 0.35.Door U-values must be tested and documented by the manufacturer in accordance with the NFRC test procedure or taken from the door U-value in Table 11.5.3b. If a door contains glass and an aggregate U-value rating for that door is not available, include the glass area of the door with your windows and use the opaque door U-value to determine compliance of the door. One door may be excluded from this requirement(Le„may have a U-value greater than 0.35). c)If a ceiling,wall,floor,basement wall,slab-edge,of crawl space wall component includes two or more areas with different•insulation levels,the component complies if the area-weighted average R value is greater than or equal to component.Glazing or door components comply if the area-weighted average U- the R-value requirement for that compon g equal to the U-value requirement(0.35 for doors). windo ws or doors is less than or eq . value of all w . 43 RESIDENTIAL BUILDING PERMIT FEES APPLICATION FEE New Buildings $100.00 Residential Addition $50.00 Alterations/Renovations $50.00 Change of Contractor/Builder $25.0.0 FEE VALUE WORKS19EET t NEW LIVING SPACE square feet x$96/sq.foot= x.0041= plus from below(if applicable) ALTERATIONS/RENOVATIONS OF EXISTING SPACE square feet x$64/sq.foot= x.0041= plus from below(if applicable) . GARAGES*(attached&detached) _square feet x$32/sq.ft._ x.0041= ACCESSORY STRUCTURE>120 sq.ft. >120 sf-500 sf $35.00 >500 sf-750 sf 50.00 >750 sf- 1000 sf 75.00 >1000 sf- 1500 sf 100.00 >1500 sf-Same as new building permit: square feet x$96/sq,foot= x.0041= STAND ALONE PERMITS Open Porch x$30.00= (number) Deck x$30.00= (number) Fireplace/Chimney x$25.00= (number) Inground Swimming Pool $60.00 Above Ground Swimming Pool $25.00 Relocation/Moving $150.00 (plus above if applicable) Permit Fee Projwst lu�.,nFanna i ofE Kati Town of Barnstable Regulatory Services ` BAThomas F.Geiler,Director ass. 9 ArfQ .�b 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 Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW SUPPLEMENT TO PERMIT APPLICATION MGL c. 142A requires that the"reconstruction,alterations,renovation,repair,modernization,conversion, improvement,removal,demolition,or construction of an addition to any pre-existing owner-occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. Type of Work: (` . Estimated Cost Address of Work:_rc�. GiA V► (K, Owner's Name: Date of Application: I hereby certify that: Registration is not required for the following reason(s): OWork excluded by law ❑Job Under$1,000 OBWlding not owner-occupied 2Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH.UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date Contractor Name Registration No. OR �. �f A(Aild-4 Date wner's Nam Q:forms:homeaffidav t , M , r N. . � 'ice •! �\ 1 v S y,.. •F � � � ,,. '�y,.�:. .�` � tit `}�xv t it t is l� I{i al�� �J l' rest - Sal � ..� ���� � t R i P��� �� � �� "" r" t +f_}iYs��J�.ft� I \�� � �.Y•3*,,t�o m'v yL�; ! s+ ^ �.1 .� ,, at mac,,.+L! �.�.. � t �'^� �.1 h,�71a�..c � i�' L PI i��.� �:a r' •�-I ! S ���t f i r '�� I•'.�<F I, � ,�' :9'a - ,.,�_ '�4 v. yy �� ..y 4 i�i� •I„��.. � �4'' t ��21 ...r ! � ."� t � -b 1-9�.� a" .. � a .m"�l` �� 'tea �' '' n�, _sic s�rr �� �� � .r• J i ,'.SI I Es ,v-i.. � �: R 3 1 r Z�}., •yvi f.:.,�^"-.^7.y•.. .. .�y :'. 3�t..•' ;Y..�i� �':s e.� � ""+'+z.- >..- �� � �`pf� ��7; ` �w,/ �`�� t ,_1.,�1\ `' �,�.:-, � :.::.. ,;,... ,_._�,�t._�./�,,s, '2�- T•.= �.'ca` %� y :ax �5.,, P ';3�. \ -;t•.j F��.<,�p.���0 ,.�'�i� � .,-.. •.:Z � l ... f n,'.. '-�.;>� .,�.��. a���„r/�'r_�{�S' ,.\,' �i'�f•-•.i�.tr. lA"4�.-'�Ka�' a � iH�t 1`� :'t'� r ,;; � '7{;.':•.aY���i�lt �'� .. ,.I Ir` �• I } -. r�'.� • SAP'45'rARLE, Logged In As: Parcel Detail Tuesday,August 20 2013 Parcel Lookup Parcel Info Parcel ID I309-255 I Developer!LOT 27 Lot`• Location 172 GROVE STREET I Pri Frontage 78 Sec Road 1PINE COURT -- I Sec 90 Frontage Village jHYANNIS I Fire District HYANNIS Town sewer exists at this address No I Road Index r0639 Asbuilt Septic Scan: Interactive LC'la ` 4 309255 1 Map . - $.': Owner Info ownerAUSTIN, PATRICIA�— Co-owner`,,%MILLER, HEATHER Streeti i 112 WAYLAND ROAD I street2 j City'HYANNIS I state-MA zip i02601 Country j J Land Info Acres 10.14 Use Single Fam MDL-01 I Zoning'RB . Nghbd j0104� Topography Level Road;Paved � _I Utilities(Public Water,Gas,Septic I Location Construction Info Building 1 of 1 _ Year r---__—_.____ _— Roof Built!1940 I Struct!Gable/Hip Wall Wood Shingle Living I1485 — Cover ASph/F GIs/Cmp AC None — — Area Cooven Type Int style jCape Cod ( Wail lDrywall Rooms,3 Bedroom Model'Residential Int Carpet Bath 1 Full Floor Rooms AV a er I Heat _•_ _ ___._....._._ Total Grade ge Plus Type H ; of Water Rooms;5 Rooms Heat} Found Stories'1.31T— __ -- -_I Fuel+Gas ation Conc. Block Gross Area 12945 Permit History http://issgl2/intranet/propdata/PareelDetail.aspx?ID=25528 8/20/2013 Issue Date Purpose Permit# Amount Insp Date Comments 11/8/2005 Other 188243 $15,000 3/30/2006 12:00:00 AM IX-APT Visit History_A_ !_ Date Who Purpose 7/20/2011 12:00:00 AM Jeff Rudziak In Office Review 4/14/2009 12:00:00 AM Karen Perry In Office Review 10/8/2008 12:00:00 AM Michele Arigo Change of Address 8/20/2007 12:00:00 AM Tony Podlesney In Office Review 3/30/2006 12:00:00 AM Martin Flynn CALLBACK 11/7/2005 12:00:00 AM Jason Streebel Mea+Corrected Listing 11/2/2004 12:00:00 AM Martin Flynn CALL BACK 6/16/2003 12:00:00 AM Paul Talbot Meas/Listed-Interior Access 7/25/2002 12:00:00 AM Paul Talbot Meas/Est 11/15/1987 12:00:00 AM ML Meas/Listed-Interior Access Sales History Line Sale Date Owner Book/Page Sale Price 1 10/18/2005 AUSTIN, PATRICIA 20378/070 $300,000 2 1/18/2005 SAFE HARBOR REAL ESTATE, LLC 19450/071 $208,000 3 2/3/2003 LOPES, PAUL E 16342/322 $285,000 4 1/7/2003 MAGLIOCCA,JAMES F 16198/338 $120,000 5 5/15/1995 SEAVER, JOANNE M 9670/073 $1 6 10/15/1988 SEAVER, RALPH F III&JOANNE M 6499/102 $1 7 4/21/1950 LAHTEINE, LILLIAN 747/553 $0 8 RIVARD,JOANNE M*NAME CHG 1 1 51 3/270 $0 9 SEAVER, RALPH UN-REG 6499/102 $0 10 3/15/2013 1MILLER, HEATHER 27212/350 $100,000 - Assessment History Save# Year Building Value XF Value OB Value Land Value Total Parcel Value 1 2013 $139,600 $30,900 $4,300 $62,000 $236,800 2 2012 $142,700 $24,500 $3,400 $62,000 $232,600 3 2011 $141,200 $8,100 $0 $62,000 $211,300 4 2010 $140,700 $8,100 $0 $95,400 $244,200 5 2009 $149,000 $7,200 $0 $132,100 $288,300 6 2008 $154,800 $7,200 $0 $137,700 $299,700 8 2007 $124,000 $0 $9,800 $137,700 $271,500 9 2006 $90,100 $0 $6,800 $140,600 $237,500 10 2005 $80,900 $0 $7,100 $122,500 $210,500 11 2004 $47,100 $0 $7,200 $122,500 $176,800 12 2003 $41,300 $0 $7,500 $33,900 $82,700 13 2002 $41,300 $0 $7,500 $33,900 $82,700 14 2001_ $34,900 $0 $7,500 $33,900 $76,300 15 2000 $27,700 $0 $8,000 $19,900 $55,600 16 1999 $27,700 $0 $6,400 $19,900 $54,000 17 1998 $27,700 $0 $6,400 $19,900 $54,000 18 1997 $28,300 $0 $0 $17,100 $49,200 http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=25528 8/20/2013 19 1996 $28,300 $0 $0 $17,100 $49,200 20 1995 $28,300 $0 $0 $17,100 $49,200 21 1994 $31,900 $0 $0 $20,500 $56,700 22 1993 $31,900 $0 $0 $20,500 $56,700 23 1992 $36,400 $0 $0 $22,800 $64,100 24 1991 $45,400 $0 $0 $37,000 $93,900 25 1990 $45,400 $0 $0 $37,000 $93,900 26 1989 $45,400 $0 $0 $37,000 $93,900 27 1988 $33,000 $0 $0 $14,400 $55,800 28 1987 $33,000 $0 $0 $14,400 $55,800 29 1 1986 1 $33,000 $0 $0 $14,400 $55,800 Photos http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=25528 8/20/2013 �hi+rp 1i � wry. n�f 07 Logged In As: Parcel Detail Tuesday,August 20 2013 Parcel Lookup Parcel Info Parcel ID 271-201-- -- Developer'LOT 48 Lot Location 112 WAYLAND ROAD l Pri Frontage64 Sec Road i I Frontage Village 1HYANNIS I Fire District HYANNIS - —I Town sewer exists at this address No I Road Index;1797 I Asbuilt Septic Scan: Interactive 271201_1 - 4 ,Y 271201_2 Map 5 .. Owner Info Owner„MILLER, HEATHER G I Co-Owner; I Streeti 112 WAYLAND ROAD I Street2 City HYANNIS State MA zip 02601 Country Land Info Acres 10.33� use ISingleFarn MDL-01-' I-^zoning RB --- - -- Nghbd;0104�- Topography i----�..—_ -----------I Road Utilities I-- Location Construction Info Building 1 of 1 Year, R0°f�Gable/Hi Ext' Built E1983 Wood Shinle— I Struct p Wall g I LArea 1092 - Covver jAsph/F GIs/Cmp T Pe CentralT-- styleRanch I Int`Drywall` - Bed`3 Bedrooms - Wall! Rooms Model Residential IntCarpet f Bath2Full Floor; Rooms r —___----- Heat j___ ._—... Total ---- --- --- Grade!Average I Type i Hot Air I Rooms!5 Rooms I Heat i.�------------ _.__-__._._ Found- Stories j 1 Story FuelGas _J ation!Poured Conc. I --- Gross 12936 _.-._I Area w Permit History http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=20588 8/20/2013 Issue Date I Purpose I Permit# I Amount I Insp Date I Comments II Visit History -- ------- -- --------...... ----- ---- --------- - ------ Date Who Purpose 7/11/2013 12:00:00 AM Geraldine Clark In Office Review 12/20/2005 12:00:00 AM Gary Brennan Meas/Listed-Interior Access 9/28/2005 12:00:00 AM Denise Radley Change of Address Sales History Line Sale Date Owner Book/Page Sale Price 1 5/17/2012 MILLER, HEATHER G C197117 $139,699 2 4/26/2012 BANK OF NY MELLON C196906 $190,000 3 9/14/2005 DECARVALHO, CLAUDIO L&MARTA M C177917 $364,000 4 8/4/2003 RYAN, MARK K&MARIANA #D933119 $100 5 10/8/2002 RYAN, ELEANOR C166840 $100 6 9/27/2001 RYAN, ELEANOR C162897 $1 7 6/6/1996 RYAN, ELEANOR #D667659 $1 8 10/15/1989 RYAN, LAWRENCE W&ELEANOR C118661 $1 9 5/15/1983 RYAN, LAWRENCE W&ELEANOR C91824 $61,500 10 10/15/1982 1 FRANCO, NICHOLAS D,TR IC89921 1 $119,600 Assessment History Save# Year . Building Value XF Value OB Value Land Value Total Parcel Value 1 2013 $88,400 $35,600 $5,500 $68,100 $197,600 2 2012 $88,400 $34,900 $4,300 $68,100 $195,700 3 2011 $124,200 $3,300 $0 $68,100 $195,600 4 2010 $124,100 $3,300 $0 $104,700 $232,100 5 2009 $120,500 $2,700 $0 $155,600 $278,800 6 2008 $146,500 $2,700 $0 $166,500 $315,700 8 2007 $145,800 $2,700 $0 $185,700 $334,200 9 2006 $127,300 $2,700 $0 $168,700 $298,700 10 .2005 $120,700 $2,700 $0 $134,500 $257,900 11 2004 $98,000 $2,700 $0 $100,800 $201,500 12 2003 $88,600 $2,700 $0 $40,900 $132,200 13 2002 $88,600 $2,700 $0 $40,900 $132,200 14 .2001 $88,600 $2,700 $0 $40,900 $132,200 15 2000 $68,500 $2,600 $0 $26,800 $97,900 16 1999 $68,500 $2,600 $0 $26,800 $97,900 17 1998 $68,500 $2,600 $0 $26,800 $97,900 18 1997 $66,500 $0 $0 $26,800 $93,300 19 1996 $66,500 $0 $0 $26,800 $93,300 20 1995 $66,500 $0 $0 $26,800 $93,300 21 1994 $65,400 $0 $0 $30,100 $95,500 22 1993 $65,400 $0 $0 $30,100 $95,500 23 1992 $74,400 .$0 $0 $33,500 $1.07,900 24 1991 $81,100 $0 $0 $46,900 $128,000 25 1990 $81,100 $0 $0 $46,900 $128,000 26 1989 $89,200 $0 $0 $46,900 $136,100 http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=20588 8/20/2013 4 27 1988 $65,500 $0 $0 $20,300 $85,800 28 1987 $65,500 $0 $0 $20,300 $85,800 29 1986 $65,500 $0 $0 $20,300 $85,800 Photos http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=20588 8/20/2013 '�rj4r63 P9193 —79651 11-10-2005 & 122 590 , Ile Town of Barnstable CF THE Ipy� ,. Regulatory Services Thomas F.Geiler,Director BARNgmBm 039. �.� Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 _ v Office: 508-862-4038 F: "508-7 .6230 AGREEMENT FOR FAMILY APARTMENT I(Wej, the undersigned, being the owner(s) of property situated at 72 GROVE STREET in MA, holding title under a deed recorded with the Barnstable County Registry of Deeds or Barns lie CounSty District Registry of the Land Courtin Book /WIL Page- 70 or as Document No. being shown on Assessors' Map 309 as Parcel 255,,hereby agree, certify, warrant and' represent to the Town of Barnstable that the accessory attached apartment,which contains living quarters,is intended for use as a family apartment,for year-round occupancy. The intended and authorized use is for EDWARD AUSTIN, BROTHER OF OWNER PATRICIA AUSTIN associated with the residential use on the same premises. This unit shall be used for a"Family Apartment' (as defined in Zoning Ordinances) which would require compliance with the Family Apartment Rules and Regulations. This unit shall not be rented as an apartment or as a single room,or in any fashion,which rental would be a violation of the Town of Barnstable's rules,regulations,and zoning ordinances. Prior to occupancy of this unit, affidavits reciting the names of occupants are to be recorded with the building department. This agreement shall be updated whenever a change occurs or every calendar year. This Agreement shall be duly recorded or filed at the Barnstable County Registry of Deeds/Land Court for the purpose of alerting future owners of the property of this binding Agreement concerning the use of the property as herein stated. The consideration for this Agreement is the issuance of a building permit and/or certificate of occupancy by the Town of Barnstable Building Department. �1 WITNESS our hands and seals this a 1 200 G day of \i TOWN OF BARNSTABLE R7 (S) .11 < ' J By: P u din CommissioneVSACHUSETT THE COMMONWEALTH OF BARNSTABLE COUNTY,SS Date_Ze Z/a a06 (owner);Then personally appeared the above-named ( ) and , made oath as to the truth of the foregoing instrument,before me. ®INSTABLE COUNTY Notary Public MARY C. GRIFFITHS REGISTRY OF DEEDS My Commission E/pirs: Notary Public A TRUE COPY,q gT MY Commission Expires Feb.' 24, 2006 JOHN F.AAEAD REiGISTER Q:w°Ta/amess°ryagreement BARNSTABLE REGISTRY OF DEEDS (� � /�--�iZ.�i/�l � y ljjr F C �� �� t 7 IN 4 � a, O � �' �» Appeal or Permit No 88243 Appeal +Building Permit ,Status New Last ' - Applicant Austin jPatricia T � ; Addr2 72 Grove Street q t Village:' ' Hyannis MA 02601 �� sAuk� . Aff Received Map Par 309 255 �Zonmg a ,« t a -Decision: � �� y . 41, v Notes g Permit to renovate garage issued 11/8/05. �t x �° s`t '� s t $ � 1 ,£ Close 4,tc-R aa r � 3 a.' *°� •t`s `�, -� n� :... --.. a= x'rw. e won -77 71 41, dol F Too' �r �+ '�� �: _ y4 �. ¢ ., .-Tom 'w .41 RA AT �`..r+ ,.� � .'. �"`aa.r ''��` °"4,. 0 k � ea -%1�''�'" S *-`':, TV ^`n . -a , a. �i a� rv'�1 y r rf av dot as c.,a "` lk s. �; ^' W* =a 1774 ✓9�hS w r„-vm �?-``..,` „ �`�`,r<a. u r ` =tE ''v ,-ti '� 3'r'x s-,: :' ,`Sa',�>,� ^effi ,.'A:s >.:�. . a y � � a � a � .;r dill _ a, � am� �. � rcas; -w`f1x, , ,[T a;E_, :, r 9 ,`�..sIj ��_.� rya,a'` ,"'°, 4` an On - ,3�'„> cq� szsel ��;�� �4 van, .:_,�a, n �;-04 »2 s � � m rr . .... __ r ;, eye f;sx c -.,. a. ,,�m ft ..r , :& # wW* u s+`x a.Ya 7,700. '. %` - .. "a d *'4 r :�� N <"va..,. S - :'i7, • y+„c� e '�'g -xaK '' ±�a 4P'F" e +a`r9R �[5";T�'�7�2r_ .. y�kn. {'�jw4w,?FI'r-.w�fr" mR^ X'R?xr��h��^"' AW . a r 44 �,., S a k ,.�.'" 9�, p - '��?., r�,'�. �� �':.: t•�,,•, -:. ,�' a `�'.g-r,,, x.:y r ,,,.��''.�^ ,=^i �,' � � �,�:'r.��adM.a ,'':. e`�1..3 '!�e �.'> ,'�. ' id'�i �,„.. �" - r".; :.:....'. ,..--.., ,�, A .:'...._ _ .`.r,:..' ,.. 't��k^�'`'s' �,"+„4fi .k. vEa,.+r«::. ^� ': ,�'f•'S,er„`"`�S iz�....i..m.. '§.`a,''r-'m�, .-�s*� ,S�um��-»$.,�;.',� 'S�"',?�" :','h . h '� s '..wy� +�e:• ., .�i°-£i; 'r",'� �.;.,� � .r77 VR �., � a r 3a^..:. 77, +^rr+,,.u... .-�+r""C"^"^"^ '+«'+ ; . _ f ,d ;w ✓ ye /Of THE-✓��\ '.."tom +^.. f EARNSTAti1)= MAwS Logged In As: Parcel Detail Tuesday,August 20 2013 Parcel Lookup Parcel Info Parcel ID 309-268-___ I Developer LOT 1 Lot Location 1120 BEARSE'S WAY I Pr Frontage`;20 Sec Road( Sec I Frontage' Village 1HYANNIS —� - -- _ I Fire District!HYANNIS Town sewer exists at this address;Yes I Road Index;0109 �z Interactive Map Owner Info owner IM LI;M LI LER, HEATHER G (�Co-Owner .- - -_ . Streets�i 120-0 BEARSEB __--S WAY -- -�____.. �—vI Street2 City HYANNIS State MA- Zip 02601--- Country . Land Info Acres 0.13 Use Single Fam MDL-01 I Zoning AB Nghbd 0104 Topography iLevel -- — Y I Road.Paved Utilities iAll Public,Gas I Location Construction Info Building 1 of 1 Year 1930 Gable/Hip Ext Wood Shingle _ Built' Struct• Wall } Living 1480 I AC`None Area _J Cover over jAsph/F Gls/Crop Type'• Style;Ranch IntWall Brd/Wood Bed"2 Bedrooms Wall! Rooms Model!Residential v Floor _I Bath Rooms Floor� 1 Full Total Grade Below Average Type;Hot Water ! I Rooms A RoomsHeat _�- -.._r------- Found- Stories;1 Story—_ I Fuel±Gas ation Poured Conc. Gross i495 -95._---------_ Area i495 Permit History ---- _._... -- http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=25542 8/20/2013 tIssue Date I Purpose I Permit# Amount I Insp Date I Comments II Visit History Date Who Purpose 7/15/2013 12:00:00 AM Pamela Taylor In Office Review 6/9/2003 12:00:00 AM Paul Talbot Meas/Est 2/27/2003 12:00:00 AM Paul Talbot Meas/Est 3/20/2001 12:00:00 AM SM Meas/Listed-Interior Access 12/15/1987 12:00:00 AM IML I Meas/Listed-Interior Access - Sales History Line Sale Date Owner Book/Page Sale Price. 1 8/4/2009 MILLER, HEATHER G 23941/72 $83,750 2 11/17/2006 BORTHWICK, KATHARINE A 21533/23 $194,000 3 6/19/2002 VOEGELI, KEVIN L&ALICIA 15280/140 $119,500 4 8/24/2001 ELWELL,TODD 14171/223 $79,000 5 1/15/1982 1 ARVANITIS,JAMES J &MARIATRS 3423/339 1 $0 Assessment History Save# Year Building Value XF Value OB Value Land Value Total Parcel Value 1 2013 $33,700 $800 $0 $61,600 $96,100 2 2012 $33,700 $700 $0 $61,600 $96,000 3 2011 $40,600 $0 $0 $61,600 $102,200 4 2010 $40,600 $0 $0 $94,800 $135,400 5 2009 $37,400 $0 $0 $131,600 $169,000 6 2008 $43,500 $0 $0 $137,000 $180,500 8 2007 $43,500 $0 $0 $137,000 $180,500 9 2006 $44,100 $0 $0 $140,400 $184,500 10 2005 $42,400 $0 $0 $121,900 $164,300 11 2004 $32,600 $0 $0 $73,100 $105,700 12 2003 $28,300 $0 $0 $33,800 $62,100 13 2002 $28,300 $0 $0 $33,800 $62,100 14 2001 $28,300 $0 $0 $33,800 $62,100 15 2000 $24,000 $0 $0 $19,900 $43,900 16 1999 $24,000 $0 $0 $19,900 $43,900 17 1998 $24,000 $0 $0 $19,900 $43,900 18 1997 $16,500 $0 $0 $17,100 $33,600 19 1996 $16,500 $0 $0 $17,100 $33,600. 20 1995 $16,500 $0 $0 $17,100 $33,600 21 1994 $18,200 $0 $0 $20,500 $38,700 22 1993 $18,200 $0 $0 $20,500 $38,700 23 1992 $20,700 $0 $0 $22,800 $43,500 24 1991 $24,600 $0 $0 $37,000 $61,600 25 1990 $24,600 $0 $0 $37,000 $61,600 26 1989 $24,600 $0 $0 $37,000 $61,600 27 1988 $27,000 $0 $0 $14,000 $41,000 28 1987 $27,000 $0 $0 $14,000 $41,000 11 29 1 1986 1 $27,000 $0 $0 $14,0001 $41,000 11 http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=25542 8/20/2013 i � Photos http://issgl2/intranet/propdata/PareelDetail.aspx?ID=25542 8/20/2013 Town of Barnstable Building Department �oF rOkt, Brian Florence,CBO 00 Building Commissioner snmvsrxar�, 200 Main Street,Hyannis,MA 02601 ss�as www.town.barnstable.ma.us ��fD MA'S a Office: 508-862-4038 Fax: 508-790-6230 Approved: Fee: Permit#: HOME OCCUPATION RkGISTRATION Dater Name: JAI l I 94C N& ,Lg"hone#: ' Address: 0 U 1- 5 1- H W A) , Village: A)-( f)l L F Name of Business: �( f 1 A, 9 I E ( l � �,11!11� � O r F 55 f 0 A)6,� .5 Type of Business: 1 f5 0 /A1( a (ff is - Map/Lot: INTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation within single family dwellings,subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the activity shall not be discernible from outside the dwelling:.there shall be no increase in noise or odor;no visual alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes;and no increase in air or groundwater pollution. After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to the following conditions: • The activity is carved on by the permanent resident of a single family residential dwelling unit,located within that dwelling unit. Such use occupies no more than 400 square feet of space. • There are no external alterations to the dwelling which are not customary in residential buildings,and there is no outside evidence of such use. • No traffic will be generated in excess of normal residential volumes. • The use does not involve the production of offensive noise,vibration,smoke,dust or other particular matter,odors,electrical disturbance,heat,glare,humidity or other objectionable effects. There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess of normal household quantities. • Any need for parking generated by such use shall be met on the same lot containing the Customary Home Occupation,and not within the required front yard. • There is no exterior storage or display of materials or equipment. • There are no commercial vehicles related to the Customary Home Occupation,other than one van or one pick-up truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lot containing the Customary Home Occupation. • No sign shall be displayed indicating the Customary Home Occupation. • If the Customary Home Occupation is listed or advertised as a business,the street address shall not be included • No person shall be employed in the Customary Home Occupation who is not a permanent resident of the dwelling unit. I,the undersigned,have read and agree with the above restrictions for my home occupation I am registering. Applicant: '�,4l�.IL/NF L(dj,S�� 1f�1� gA 0 SA- Date: ©l 12 (a/aa n Homeoc.doc Rev.10/17 i Town of Barnstable Building Department Brian Florence, CBO Building Commissioner 200 Main Street, Hyatnnis, MA 02601 www.town.bamsfable.ma.us Pre-application for Business Certificate Date Map Parcel Applicant Information Applicants Name ��� LL INC Applicants Address ST Email Address 'T 4Y OUT L 00k_C o Telephone Number `���� J`D ' �� Listed ❑ Unlisted ❑ Business Information New Business? Ye No Business is a registered corporation? ------------------------- Yes No If yes Name of Corporation Does business operate under the registered corporate name? Yes No Is the business a sole proprietorship or home occupation? --------- Yes No If yes then a Home Occupation Registration is required—See Building Division Staff Name of Business Business Address l� G R b VC ST . Type of Business CL C, ,) N bl� S M l c(s Building Commissioner Office Use Only Conditions Building Commissioner Date Clerk Office Use Only Any individual, partnership or corporation doing business under a name, other than their own. name or incorporated name, must file a Business Certificate. Any individual, partnership or corporation doing business under a name, other than their own name or incorporated name, must file a Business Certificate. The certificate fee is $40.00 and is valid for 4 years. The Business Certificate form is must be submitted to the Building Division for review and signoft.by the Building Commissioner. The form is then submitted to the Town Clerk's Office for processing. Town Clerk Building Commissioner Barnstable Town Ilall Town Offices 367 Mail St, Hyannis 200 Main St, Hyannis 508.862.4044 508.862.4038 ` Under the provisions of Chapter 337 of the Acts of 1985 and. Chapter 110, Section 5 of the Mass. General Laws, business certificates shall be in. effect for four years from the date of issue and. shall be renewed each four years thereafter. A statement under oath must be filed.with the Town Clerk upon discontinuance or withdrawing from such business or partnership. Copies of suCh. certificates shall be available at the address such business is conducted and shall be furnished upon request during regular business hours to any person who has purchased.goods or services from such. business. Violations are subject to a fine of not more than three hundred dollars, ($300.00) for each month. during which such violation occurs. The issuance of a Business Certificate does not imply that all relevant licenses required to legally operate this business have been obtained or are current. This certificate only records that a business is being conducted. � � � 3,7 1 ti Application number.... 1. ).\ Fee .... ..... GU ^` ................... �...D�............................... s •I'Y� i �9 �. w Building Inspectors Initials.... Ak64 Date Issued...8. .................................................... J.9.1 25S .MaP/Parcel...... ........ ............... TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDOWS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: 2 6 Z.O V e a V`IA k�s NUM BER STREET VILLAGE Owner's Name: (D7-0 ZD Uh t ,I Phone Number / ��' S� 0 Email Address:To U L M d 64 M F COW Cell Phone Number Project cost$ O LQ L9•- O 0 Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: Date: TYPE OF WORK ❑ Siding Windows (no header change)# 0 Insulation/Weatherization Doors(no header change)# _ Commercial Doors require an inspector's review ❑ Roof(not applying more than 1 laye f shingles) Construction Debris will be going to ® t S CONTRACTOR'S INFORMATION Contractor's name Home Improvement Contractors Registration(if applicable)# (attach copy) Construction Supervisor's License# (attach copy) Email of Contractor Phone number ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR/F THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT. YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. APPLICATION NUMBER *For Tents Only* Date Tent(s)will be erected Removed on number of tents total �l Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one:this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached. Provide a site plan with-the location(s) of each tent Fuel source being used LP tank 20 lbs. or>Yes No ,if yes, a gas permit is required. Natural Gas Yes No , if yes, a gas permit is required. If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9:30 am or 3:30 pm-d:30pm. Commercial events may require Fire Department approval, *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: /Vt 0?v`zo V f/- L 7-T Telephone Number ro 17 Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Tow stable. Signature / Date tF a 6. / APPLICANT'S SIGNATURE Signature Date 9 All permit a -1-cations are subject to a building official's approval prior to issuance. e 1 QX The Commonwealth of Massachusetts Department of Industrial Accidents ' - Office of Investigations 600 Washington Street Boston,MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): .4 G0 1e"-1/'L0 /"�(�01-0 2of/4 Address: City/State/Zip: PY 12 "il. C, )14 (91 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. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7.,❑Remodeling ship and have no employees These sub-contractors have g• ❑Demolition working for in an capacity. employees and have workers' g Y P tY 9. ❑Building addition [No workers' comp.-insurance comp.insurance.t k ' required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.�rI 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company 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 certify un r the pains and penalties of perjury that the information provided above is tru e and correct. Si ature: Date:. / Phone#: b / ��� S® O,6 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): g 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: i s �+ Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their 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 permittlicense 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 E Tel.#617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax#617-727-7749 www,maw.gov/dia r Mass. Corporations, external master page Page 1 of 2 , h Corporations Division Business Entity Summary • 001282873 Re uest certi._. ....,_ ID Number • �q ficate� New search Summary for: MOROZOVA-ENTERPRISE;-LLC The exact name of the Domestic Limited Liability Company (LLC): MOROZOVA ENTERPRISE, LLC Entity type: Domestic Limited Liability.Company (LLC) Identification Number: 001282873 Date of Organization in.Massachusetts: 07-19-2017 Last date certain: The location or address where the records are maintained:(A PO box is not a valid location or address): Address: 2400 MEETINGHOUSE WAY - City or town, State, Zip code, WEST"BARNSTABLE, MA 02668 USA Country: The name and address of the Resident Agent: Name: LAWRENCE P. MAYO Address: 80 WASHINGTON SQUARE UNIT C20 City or town, State, Zip code, NORWELL, MA 02061 USA Country: The name and business address of each Manager: Title ___._._._.__.__._._.____ Individual name `Address In addition to the manager(s), the name and business address of the person(s) authorized to execute documents to be filed with the Corporations Division: Title -Individual name Address. SOC SIGNATORY c EKATERINA-V.MOROZOVA 2400 MEETINGHOUSE WAY WEST BARNSTABLE, MA 02668 USA SOC SIGNATORY EKATERINA-V.-MOROZOVXy 2400 MEETINGHOUSE WAY WEST BARNSTABLE, MA 02668 USA http://corp.sec.state.ma.us/CorpWeb/CorpSearch/CorpSummary.aspx?FEIN=001282873&S... 8/6/2019 Mass. Corporations, external master page Page 2 of 2 The name and business address of the person(s) authorized to execute, acknowledge, deliver, and record any recordable instrument purporting to affect an interest in real property: Title Individual name Address REAL PROPERTY EKATERINA V. MOROZOVA 2400 MEETINGHOUSE WAY.WEST BARNSTABLE, MA 02668 USA REAL PROPERTY EKATERINA V. MOROZOVA 2400.,MEETINGHOUSE WAY WEST BARNSTABLE, MA 02668.USA ❑ ❑Confidential ❑Merger ❑ Consent Data Allowed Manufacturing View filings for this business entity: ALL FILINGS Annual Report Annual Report - Professional «' Articles of Entity Conversion Certificate of Amendment View filings Comments or notes associated with this business entity: ._._.._._....._._.___.._._...__._.....__...___.............:..__.._.._._._...___..__.__.._. _.___.___..._...__...._._....__._T__m_____._._ .___.___, _._.___._.. __...m.__._...._..._ _.....:...._._ _._..._...._. I ....... .. ... . . New search http://corp.sec.state.ma.us/Corp Web/CorpSearch/CorpSummary.aspx?FEIN=001282873&S... 8/6/2019 Parcel Detail Page 1 of 5 3 1! MASS: r 4695.e �O+Ur , 7 . �^ Tj�,��j °.��`Fn f>7 �✓ '.PST/'!://GPr:?t/ � Logged in As: Parcel Detail Tuesday,August 6 2019 Parcel Look.,, Parcel Info ............... _.._.._....r.... _r. p. Parcel ID 309-255 ') Developer Lot"1LOT 27 Location 72 GROVE STREET Pri Frontage 78 i Sec Road#PI NE COURT"F--��� i Sec Frontage Village Hyannis Fire District YANNIS �.AI Town sewer exists at this address rko -�. Road Index 0 9 � v sv Asbuilt Septic Scan: Interactive Map x� 309255_1 d <- Owner Info Owner NOWEL,ALEXANDRA Vi co- 0 %MOROZOVA ENTERPi wner Streetl#2400 MEETINGHOUSE li streetz city IWEST W-R-NS TA E(71state AMA zip°02668 (country Land Info ......... Acres 0.14 .v... :, f use ISingle Fam MDL-01 I zoning FRB i Nghbd;0104 i Topography Leve'i f , Road r,Raved Utilities Public Water,Gas,Septi]. Location r Construction"Info Building 1 of 2 Year ".r swoc Gable/Hip:,,,..m..,,.:J �,tWood Shingle ,.;:. all Livia 1428 f Roof fAs h/F GIs/Cm AC[None Area% J Cover- p p Type i, Bed Style Cape Cod J wall Drywall Rooms'3 Bedrooms Model Residential Fi o�IHardwood R oms 0 Full-0 Half ,,,,:F, , Grade Average Minus Type Hot Water Rooms 5 Rooms Heat ound- Stories 4 yYT� Y Fuel[gas F anonMlXed Gross 12236 mm Area Building 1 of 2 ,1940 « Roof Gable/Hip E'� Year wall T111f Siding< Y. Built i_ struct& n Living 1428 Roof Asph/F GIs/Cmp� TyAC pe pe[None,, J Area 4 Cover my 5 nt Bed style�RanchF � . Wall p�Drywall Rooms Model iResidentialra Floor€Minimum/Plywd Rooms 1 Full OWHaIf cn� Grade Average Minus Type�None� � �� Rooms � <_� http://issgl2/intranet/propdata/ParcelDetaii.aspx?ID=25528 8/6/2019 f Parcel Detail Page 2 of 5 Stories ., ., I Heat ,,u,,,. Found ,,,. :,,,,. . i1 Story 1 Fuel None ation Blk/Pour Ftgs Grossi Area 7 ¢W .::._.... ............. _ ................. ........... . Permit History Issue Date Purpose Permit# Amount Insp Date Comments 11/8/2017 Sid/Wind/Roof/Door 17-3894, $2,193 replacement windows (3) Uvalue .29 2/25/2016 Insulation 16-327 $1,500 Weatherization 1/2/2014 Expired 201400026 $0 EXPIRED - REPIPE TOILET 6/30/2014 5/13/2013 New Siding 201303115 $4,000 12:00:00 RESIDE AM 4 6/30/2014 REROOF, STRP OLD 4/8/2013 New Roof 201302159 $5,800 12:00:00 AM SHINGLES EXPIRED -SERVICE ON 7/19/2006 Expired 20061971 $0 FAM APT OK'D,WIRE CONY BTH, BD, KIT, LIVRM 3/30/2006 WITHDRAWN-APT- 11/8/2005 Withdrawn 88243 $15,000 12:00:00 FAMILY, ATT GAR TO AM DW Visit History Date Who Purpose 8/8/2017 12:00:00 AM Mary Dechant Change of Address 4/17/2014 12:00:00 AM Nancy Finch Owner Requested Review 1/29/2014 12:00:00 AM Jeff Rudziak In Office Review 7/20/2011 12:00:00 AM Jeff Rudziak In Office Review 8/20/2007 12:00:00 AM Tony Podlesney In Office Review 3/30/2006 12:00:00 AM Martin Flynn CALL BACK 11/7/2005 12:00:00 AM Jason Streebel Mea+ Corrected Listing 11/2/2004 12:00:00 AM Martin Flynn CALL BACK 6/16/2003 12:00:00 AM Paul Talbot Meas/Listed-Interior Access 7/25/2002 12:00:00 AM Paul Talbot Meas/Est 11/15/1987 12:00:00 AM ML Meas/Listed-Interior Access • Sales History _. ,._.. , _. .._ _.. ........ ___...._ . ..:.................... .. Line Sale Date Owner Book/Page Sale Price 1 12/27/2013 NOWEL, ALEXANDRA V& ELEONORA 27908/348 $167,500 2 3/15/2013 MILLER, HEATHER 27212/350 $100,000 3 10/18/2005 AUSTIN, PATRICIA 20378/70 $300,000 4 1/18/2005 SAFE HARBOR REAL ESTATE LLC 19450/71 $208,000 http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=25528 8/6/2019 f Parcel Detail Page 3 of 5 5 2/3/2003 LOPES, PAUL E 16342/322 $285,000 6 1/7/2003 MAGLIOCCA, JAMES F 16198/338 $120,000 7 6/19/1998 RIVARD, JOANNE M 11513/270. $0 8 5/16/1996 SEAVER, JOANNE M 9670/73 $1 9 10/28/1988 SEAVER, RALPH F III'&JOANNE M 6499/102 $1 10 4/21/1950 LAHTEINE, LILLIAN 747/553 $0 11 7/31/2019 MOROZOVA ENTERPRISE LLC = 32193/341 $250,000 . Assessment History _.___.._: _.__._... .........-_. _ ._ Save Year Building XF Value OB Value Land Value Total Parcel # Value Value 1 2019 $109,100 $7,900 $0 $77,600 $194,600 2 2018 $88,500 $7,900 $0 $81,700 $178,100 3 2017 $82,500 $8,100 $0 $62,500 $153,100 4 2016 $82,500 $8,100 $0 $67;300 $157,900 5 2015 $90,700 $8,500 $0 $62,000 $161,200 6 2014 $139,600 $30,900 $4,200 $62,000 $236,700 7 2013 $139,600 $30,900 : $4,300 $62,000 $236,800 8 2012 $142,700 $24,500 $3,400 $62,000 $232,600 9 2011 $141,200 $8,100 $0 $62,000 $211,300 10 2010 $140,700 $8,100 $0 $95,400 -$244,200 11 2009 $149,000 $7,200 $0 $132,100 $288,300 12 2008 $154,800 $7,200 .$0 $137,700 $299,700 14 2007 $124,000 $0 $9,800 $137,700 $271,500 15 2006 $90,100 $0 $6,800 $140,600 $237,500 16 2005 $80,900 $0 $7,100 $122,500 $210,500 17 2004 $47,100 $0 $7,200 $122,500 $176,800 18 2003 $41,300 $0 $7,500 $33,900 $82,700 19 2002 $41,300 $0 $7,500 $33,900 $82,700 20 2001 $34,900 $0 $7,500 $33,900 $76,300 21 2000 $27,700 $0 $8,000 $19,900 $55,600 22 .1999 $27,700 $0 $6,400 $19,900 $54,000 23 1998 $27,700 $0 $6,400 $19,900 $54,000 24 1997 $28,300 $0 $0 $17,100 $49,200 25 1996 $28,300 $0 $0 $17,100 $49,200 26 1995 $28,300 $0 $0 $17,100 $49,200 27 1994 $31,900 $0 $0 $20,500 $56,700 28 1993 $31,900 $0 $0 $20,500 - $55,700 29 1992 $36,400 $0 $0 $22,800 $64,100. 30 1991 $45,400 $0 $0 $37,000 $93,900 31 1990 $45,400 $0 $0 $37,000 $93,900 t 32 1989 $45,400 $0 $0 $37,000 $93,900 33 1988 $33,000 $0 $0 $14,400 $55,800 34 1987 $33,000 $0 $0 $14,400 $55,800 http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=25528 8/6/2019 • k it t aK, Hall R. S�wW. s rrC qUi kk ; y Aq } .A �411rs 014 s SP ^ v a $ � \ >ram"' . { e 2 � Y\ Wx"N ' a' _gw � R1 14 r 201, Parcel Detail Page 5 of 5 �'k y Y aI ktii Mr I .. ra ! J, T)' tt. Ay „ AS'� f u http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=25528 8/6/2019 Mass. Corporations, external master page Page 1 of 2 6 �SZ.1t0�.fJ(I n n Corporations Division Business Entity Summary v _... W ID Number: 001282873 1 Request.certificate 1 New search Summary for: MOROZOVA ENTERPRISE, LLC The exact name of the Domestic Limited Liability Company (LLC): MOROZOVA ENTERPRISE, LLC Entity type: Domestic Limited Liability.Company (LLC) Identification Number: 001282873 Date of Organization in Massachusetts: . 07-19-2017 Last date certain: The location or address where the records are maintained (A PO box is not a valid location or address): Address: 2400 MEETINGHOUSE WAY City or town, State, Zip code,` WEST BARNSTABLE, MA 02668 USA ' Country: The name and address of the Resident Agent: Name: LAWRENCE P. MAYO Address: 80 WASHINGTON SQUARE UNIT C20 City or town, State, Zip code, NORWELL, MA 02061 USA Country: The name and business address of each Manager: Title Individual.name Address In addition to'the manager(s), the name and business address of the person(s) authorized to execute documents to be filed,with`the Corporations Division: Title Individual name Address SOC SIGNATORY EKATERINA V. MOROZOVA 2400 MEETINGHOUSE WAY WEST BARNSTABLE, MA 02668 USA' SOC SIGNATORY EKATERINA V. MOROZOVA 2400 MEETINGHOUSE WAY WEST BARNSTABLE, MA 02668 USA http://corp.sec.state.ma.us/CorpWeb/CorpSearch/CorpSummary.aspx?FEIN=001282873&S...- 8/6/2019 fAz\ SAR.4S7,tli1E i . Nims Logged In As: Pa rice I Detail Tuesday,August 20 2013 Parcel Lookup Parcel Info Parcel ID 309-255 I Developer LOT 27 Lots Location j72 GROVE STREET Pri Frontage'78 i Sec Road aPINE COURT � sec90 ---�`�-- -`�-�— Frontage VillagejHYANNIS Fire District HYANNIS Town sewer exists at this address No N ( Road Index M39— — — Asbuilt Septic Scan: Interactive ` 4' 309255_1 Map - Owner Info owner AUSTIN, PATRICIA I Co-owner %oMILLER, HEATHER ---.-------- r---------------- _ -_.— _ —-- Streetl 112 WAYLAND ROAD Street2l City tHYANNIS^----^-� State AMA I Zip 02601 Country j - Land Info Acres 10.14 Use ngle Fam MDL-01 ISi I ,Zoning!RB Nghbd 0104 Topography rLevel Road Paved Utilities Public Water,Gas,Septic f Location Construction Info Building 1 of 1 Year 111940 I Roof`Gable/Hip ;Wood Shingle Built Struct' Wallall Livin Roof AC g i 1485 v-�� iAs h/F GIs/Cm .None y- Area I Cover p p Type I Style jCape Cod Int D- all Bed 3 Bedrooms Wall Rooms' Model(Residential Int,Carpet _ Batn; Full Floor Rooms AVee Grade a PIUS _ Heat; — `-- Total _ — g - Type I Hot Water Y Rooms'5 Rooms Heat: Found- Stories 11.3 J Fuel:Gas _ ation;Cone. Block J Gros Area;2945 Permit History http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=25528 8/20/2013 Issue Date Purpose Permit# Amount Insp Date Comments 11/8/2005 Other �88243 $15,000 13/30/2006 12:00:00 AM IX-APT - Visit History _ Date Who Purposey 7/20/2011 12:00:00 AM Jeff Rudziak In Office Review 4/14/2009 12:00:00 AM Karen Perry In Office Review 10/8/2008 12:00:00 AM Michele Arigo Change of Address 8/20/2007 12:00:00 AM Tony Podlesney In Office Review 3/30/2006 12:00:00 AM Martin Flynn CALL BACK 11/7/2005 12:00:00 AM Jason Streebel Mea+Corrected Listing 11/2/2004 12:00:00 AM Martin Flynn CALL BACK 6/16/2003 12:00:00 AM _ Paul Talbot Meas/Listed-Interior Access 7/25/2002 12:00:00 AM Paul Talbot Meas/Est 11/15/1987 12:00:00 AM IML Meas/Listed-Interior Access Sales History Line Sale Date Owner Book/Page Sale Price 1 10/18/2005 AUSTIN,PATRICIA 20378/070 $300,000. 2 1/18/2005 SAFE HARBOR REAL ESTATE, LLC 19450/071 $208,000 3 2/3/2003 LOPES, PAUL E 16342/322 $285,000 4 1/7/2003 MAGLIOCCA,JAMES F 16198/338 $120,000 5 5/15/1995 SEAVER,JOANNE M 9670/073 $1 6 10/15/1988 SEAVER, RALPH F III&JOANNE M 6499/102 $1 7 4/21/1950 LAHTEINE, LILLIAN 747/553 $0 8 RIVARD,JOANNE M`NAME CHG 1 1 51 3/270 $0 9 SEAVER, RALPH UN-REG 6499/102 $0 10 3/15/2013 1 MILLER, HEATHER 27212/350 $100,000 - Assessment History Save# Year Building Value XF Value OB Value Land Value Total Parcel Value 1 2013 $139,600 $30,900 $4,300 $62,000 $236,800 2 2012 $142,700 $24,500 $3,400 $62,000 $232,600 3 2011 $141,200 $8,100 $0 $62,000 $211,300 4 2010 $140,700 $8,100 $0 $95,400 $244,200 5 2009 $149,000 $7,200 $0 $132,100 $288,300 6 2008 $154,800 $7,200 $0 $137,700 $299,700 8 2007 $124,000 $0 $9,800 $137,700 $271,500 9 2006 $90,100 $0 $6,800 $140,600 $237,500 10 2005 $80,900 $0 $7,100 $122,500 $210,500 11 2004 $47,100 $0 $7,200 $122,500 $176,800 12 2003 $41,300 $0 $7,500 $33,900 $82,700 13 2002 $41,300 $0 $7,500 $33,900 $82,700 14 2001 $34,900 $0 $7,500 $33,900 $76,300 15 2000 $27,700 $0 $8,000 $19,900 $55,600 16 1999 $27,700 $0 $6,400 $19,900 $54,000 17 1998 $27,700 $0 $6,400 $19,900 $54,000 18 1997 $28,300 $0 $0 $17,100 $49,200 http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=25528 8/20/2013 19 1996 $28,300 $0 $0 $17,100 $49,200 20 1995 $28,300 $0 $0 $17,100 $49,200 21 1994 $31,900 $0 $0 $20,500 $56,700 22 1993 $31,900 $0 $0 $20,500 $56,700 23 1992 $36,400 $0 $0 $22,800 $64,100 24 1991 $45,400 $0 $0 $37,000 $93,900 25 1990 $45,400 $0 $0 $37,000 $93,900 26 1989 $45,400 $0 $0 $37,000 $93,900 27 1988 $33,000 $0 $0 $14,400 $55,800 28 1987 $33,000 $0 $0 $14,400 $55,800 29 1 1986 1 $33,0001 sol $0 $14,4001 $55,800 ' � Photos http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=25528 8/20/2013 Town of Barnstable Permit# _ �o Expires 6 months from issue date s a Regulatory Services •Fee • BAENSUBLE. e •o 9$ . `0�` Richard V.Scali,Interim Director Building Division Tom Perry,CBO,Building Commissioner `k 200 Main Street,Hyannis,MA 02601 NOV 0 8 2017 www.town.bamstable.ma.0 Office: 508-862-4038 ®VVN OF rj�� il 8-790-6230 . EXPRESS PERMIT APPI6YCATION - RESIDENT1 s _ Nof Valid without Red X-Press Imprint Map/parcel Number 30 ' 2 5- Property'Address 7L G(p✓eS Residential Value of Work S 6fl ct '3 Minimum fee of S35.00 for work under$6000.00 , Owner's Name&Address �� S�Gl N 0 t✓ 7� - rovesSt -4A Qlln i A O D Contractor's Name-r E P OT Tel one Number Home Improvement Contractor License T(if applicable)!/Z 7 8 5 _ Email: Construction Supervisor's License#(if applicable) `105'Y 9 s - [ Workmi h's Compensation Insurance Check one: ❑ I am a sole proprietor 1 ❑ I am the Homeowner I have Worker's Compensation'Insurance It r Insurance Company Name /V A'T t,>&4 .- Up i bRa�= W-s . p r Work-man's Comp.Policy# .Copy of Insurance Compliance Certificate must accompany each p mit. p Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) . [❑ e-side ; Replacement-Windows/doors/sliders.U Value - '(maximum 4 of windows 3 #of doors: Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. Separate Electrical&Fire Permits required. *Vtrfrere required Lssuance of this permit does not exempt compliance with other town department 4eQulations,i.e.Historic,Conservation,etc. ***Note: ope weer must sign Property Owner Letter of Permission. o y f the Home Improvement Contractors License&Construction Supervisors License is it SIGNATURE: Q:\WPFILES\FORMS\buildingp fo \EXPRESS.doc _ Revised 061 13 —Pt 7 f'/—Z•� ? W 6 . Home Depot Contractor License Numbers: MA: 107774, 112785 Salesperson Name and Registration Number: Janice Campbell : R-1-073-13-00016 Home Improvement Agreement Home Depot U.S.A., Inc. ("Home Depot") or Service Provider named below will furnish, install and/or service the equipment listed below at the price, terms and conditions as outlined on this form. Customer Information: Sasha Nowel New England South K431072 :1 First Name Last Name Branch Name Lead# 72 grove s I [HYA71NNIS MA 02601 Customer Address city State Zip 1(617) 898-7357 Home Phone# Work Phone# Cell Phone# sasha:nowel@gmail.com Customer E-mail Address NOTICE OF RIGHT TO CANCEL: YOU MAY CANCEL THIS AGREEMENT WITHOUT PENALTY OR OBLIGATION BY DELIVERING WRITTEN NOTICE TO HOME DEPOT AT: 908 Boston Turnpike Unit 1 Shrewsbury MA 01545 Address city State Zip or Email CustomerCancellationNorthEast@homedepot.com BY MIDNIGHT ON THE THIRD BUSINESS DAY AFTER SIGNING, UNLESS THE STATE SUPPLEMENT PROVIDES A different CANCELLATION PERIOD. THE STATE SUPPLEMENT CONTAINS A FORM TO USE IF ONE IS SPECIFICALLY PRESCRIBED BY LAW IN YOUR STATE. YOUR PAYMENT(S) WILL BE RETURNED WITHIN TEN (10) BUSINESS DAYS AFTER HOME DEPOT'S RECEIPT OF YOUR NOTICE. YOU MUST MAKE AVAILABLE FOR PICKUP BY HOME DEPOT.OR PROFESSIONAL, AT YOUR SERVICE ADDRESS, AND IN SUBSTANTIALLY THE SAME CONDITION AS WHEN DELIVERED, ANY MERCHANDISE OR MATERIALS DELIVERED TO YOU. OR YOU MAY CONTACT HOME DEPOT FOR INSTRUCTIONS REGARDING RETURN SHIPMENT AT HOME DEPOT'S EXPENSE. THE LAW REQUIRES THAT THE CONTRACTOR GIVE YOU A NOTICE EXPLAINING YOUR RIGHT TO CANCEL. PLEASE SIGN BELOW TO ACKNOWLEDGE THAT YOU HAVE BEEN GIVEN ORAL AND WRITTEN NOTICEr4RF YOUR RIGHT TO CANCEL. Ac dged by: X 10/24/2017 customer's Sig to - Date 1 Board Chuse °f Builds Department Licens�t: Con S_1Q5g959ulations and Shan Safety Constru Su&e" dardt ►NGRtD sor32 . gROCK O S N��IV N Mq py . / �\ .... CpmMissipner_" )cpiration. ti/13/Y0j8 v.� ss Urge y H004 ICOhsn`n�:+ }, Re 8istran ROVE�FNrti 1411 CONST Pirati pn, ��~0 CO�T�CTpchul RUCTI 2018 R 32 GRIP 30H ON GROUP PLC CCC TYpe: PIeRC NOON SROCkT0N sr. o 2302. PrcP The Commonwealth of Massachusetts a = Department of IndustrialAccidents 1 Congress Street,Suite 100 Boston,MA 02114 2017 ,.. ' www.massgov/diu Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information —yam Please Print Lesibly Name(Business/Organization/Individual): �� c IG 1 e��Z41.S O r\ Address: City/State/Zip: 5roj -(m I .MA gzzoz Phoney: Are you an employer?Check the appropriate box: Type of project(required): I.❑I am a employer with employees(full and/or part time).* 7. ❑New construction 2.�am a sole proprietor or partnership and have no employees working forme in 8. ❑Remodeling any capacity.[No workers'comp,insurance required.] 3. lam a homeowner doing all work m self. { ' 9. ❑Demolition ❑ � y [No workers'comp.ihsur�nce rzeuirzd.]t 10❑Building addition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I vrill ensure that all contractors either have worker'compensation insu_ar ce or as sole 11.❑Electrical repairs or additions proprietor with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contactor listed on the L—Lched sheet 13.❑Roof repairs These sub-contactors have employees and have worker'comp.insiY*ance.t ❑6.❑We are a corporatiorrand its officers have exercised their right of exz�LJtion her liGL 14. Other c. - 152,§1(4),and we have no employees.[No workers'comp.insLn—nce r u lad.j *Any applicant that checks box nl 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 ou_ide contractors must submit a new affidavit indicating such. xContractors that check this box must attached an additional sheet sho win_s tie r-~+e of th e sce-contactors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide the worker'com.D.policy numbei. lam an employer that is providing workers'conipettsation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins..Lie.M Expiration Date: -N Job Site Address: CO/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 MGL c.152,§25A is a criminal violation punishable by 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.A copy of this statement may be-forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce d'�under the pal San penalties of perjury that the information provided above is true and correct. Siansture: Date: . tt 7 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#: The Commonwealth of Massachusetts Department of IndustrialAccidents i Office of Investigations Congress Street, Suite 100 Boston,MA 02114-2017 r www.mass.gov/die Workers' Compensation Insurance Af davit:Builders/Contractors/Electricians/Plumbers Please Print Legibly APPlicant Information The Home Depot At-Home Services Name (Business/Oraanization/lndividual): Address: 908 BOSTON TPK City/State/Zip: SHREWSBURY, MA,01545 Phone 4: (508)942-6942 Are you an employer? Check the appropriaVbo_x: F6O roject(required): 1 I am a employer with 200+ 4- �1 an'a General convector and l w construction employees(full and/or part-time).* rr/ 11�111ave hired the sub-contractorsmodeling 2.❑ i am a sole proprietor or partner- listed on,the attached sheet. , These sub-contractors have molition ship and have no employeesemsloyees and have workers'p ilding addition working for me in any capacity. comp_ insurance'[No workers comp. insurance We are a corporation and its ectrical repairs or additions required.] officers have exercised their Plumbing repairs or additions 3.❑ I am a home doing all work right of exemption per MGL 12.0 Roof repairs / myself. [No workers comp. 11 c. 152, §1(4),and we have no �1 �,✓ insurance required.]T 13.[�Other!,�t �1 employees. [No workers' re lace IAt comp. insurance required.] *Am applicant that checks box is must also fill out the section below showing their workers'compensation policy information. andHomeowners who submit this hii affidavit indicating a he3!Gal sheet shooing all wing the name o the sub convect and state�.hetheren hire outside contractors must submit a eor nog those entities hayech. Contractors that employees. If the sub-contractors have employees.then must provide their workers comp.policy number. loyees. Below is the policy,and job site I am an ernplover that is providln;workers'compensation insurance for my emp f inorfnation. Insurance information. Company Name:NATIONAL UNION FIRE INSURANCE COMPANY 03101/2018 Policy_ #or Self-ins.Lic.#: XWC 65831 45(QSI) Expiration Date: City/State/Zip. Job Site Address. 7 2- 6,ale ion ge licy number and expiration dte) Attach a copy of the workers' compensation polic?declarat pa c. 152 sari lead to the owing the oimposition of criminal penaltiesaof a Failure to secure coverage as required under Section_5A ofORDER fine up to$1,500.00 and/or one-year imprisonment, asthat a coll as `yl of this statement es in the ma be forv�OardedOo the ffic of a ae of up to$250.00 a day age e violator. Be ad�nsed p Investigations of the D J>I n, "ance coverage verification. t � that the information provided above is true and correct I do herebv certifi-un, the aims az d .fPerjury � � Signature: Date: -71 Phone 4: Official use only. Do not write it,this area,to.he completed.by city or town off vial. Permit/License City or Town: # Issuing Authority(circle one): L Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5:Plumbing Inspector 6.other Phone#- Contact Person: r!i 6 t F ,� _ Office of Consumer Affairs and Business Regulation = 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Type: Supplement Card Registration: 112785 HOME DEPOT USA INC Expiration: 04/22/2019 2455 PACES FERRY RD C-11 HSC - ATLANTA,GA 30339 update Address and return card. Mark reason for change. ., :; ar,a•c=„ ❑ Address ❑ Renewal ❑ Employment ❑ Lost Card _ Office of Consumer Affairs&Business Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Supalement Card before the expiration date. If found return to: , Registration Expiration Office of Consumer Affairs and Business Regulation 112785 04/22/2019 10 Park Plaza-Suite 5170 i iOME DEPOT UST,`INC Boston,MA 02116 ANDREW SWEET 2455 PACES FERRY RD C-11 HSC r i d ithou Signature ATLANTA,GA 30339 Undersecretary DATE(MMIDIIYYYY) ACOREP CERTIFICATE OF LIABILITY INSURANCE 02�17017 L� THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO R1GHT5 UPON THE CERTIFICAOL TE HOLDER THIS FS CERTIFICATE DOES NOT AFFIRMATIVELY OR DOES NO LCONSTI AMEND, EMND OR ALTER THE A CONTRACT BETWEEN THE ISSUING NGE SURER{S By THE POLICIES AUTHORIZED BELOW. THIS CERTIFICATE OF INSURANCE 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). CONTACT PRDDUCMARSH USA,INC. PHONE a No TWO ALLIANCE CENTER 3550 LENOX ROAD,SUITE 2400 ADDRRES. ATLANTA,GA 30326 INSURERIS)AFFORDING COVERAGE NAIL o 2414? 100492 HMnBD•GhW'-17-18 INSURER A:��Ub"C12 S INSURER B Gawai insurance Company 142757 INSURED THE HOME DEPOT,INC. INSURER C:New Hampshire his Co �Z3841 HOME DEPOT U.S.A.,INC. 2455 PACES FERRY ROAD INSURER D: BUILDING C-21) INSURER E: ATLANTA,GA 30339 INsuaEa F COVERAGES CERTIFICATE NUMBER: ATLM3746387-14 REVISION NUMBER:2 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY"PERIOD DING ANY REQUIREMENT.TERM OR CONDITION OF ANY CO INDICATED. NOTWITHSTAN R MAY P NTRACT OR OTHER DOCUMENT NTH RESPECT TO WHICH THIS CERTIFICATE MAY ISSUED OERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMBS SHOWN MAY HAVE BEEN RED uCY FFF,PAID CLAIMS' �� ILSSR TYPE OF INSURANCE POLICY NUMBER M AMAIDDlYYYY MWZY 310D22 03WV1017 MM112018 EACH OCCURRENCE s 9,D OM A X COMMERCIAL GENERAL LIABILITY 1,000,OOD PREMISES Eeowaremce S CLAIMS-MADE : x i OCCUR S EXCLUDED 0 LIMITS OF POLICY XS M EXP fir$`CrMw QF S S1 M PER OCC - PERSONAL s AOV INJURY s 9,ODD R 000 GENERAL AGGREGATE s 9 OOD,DDU GEPTL AGGREGATE LIM:T APPLIES PER: PRODUCTS-COMP/OP AGG S 2,0M.000 1 PRO- I LOC s X POLICY JECT MWT831D021 0310112Di7 MMI D78 161NEDSIN LIMB - I S 1,0OO,ODO A AUTOMOBILE LIABULTY BODILY INJURY(Per Muhl S X ANY AUTO BODILY INJURY(Per acddeMI l S SCHEDULED DMG � LED SELF INSURED AUTO PH DWNED , PRBOPERpAMAGE .. NAO NO-0WNED _ S . HIREDAUTOS AUTOS _ S EACH OCCURRENCE s I UMBRELLA UAB OCCUR AGGREGATE S I EXCESS LAB CLAIMS-MADE S. DED RETENTIONS p3►p112017 03ID112018 X � OTH B WORKERS COMPENSATION WLR C49112300(TN) . G AND EMPLOYERS'LWBIL'Y YIN WC OM102423(AI(NH,N.I.VT) 103N112017" 03►0112018 E L EACri ACCfDENT S 1,060,006 AlY PROMEIMWARTNERIDIECLir111E .a N/71 I031o112D17 D3I�7Y1018 E L DISEASE-EA EMPLO s 1,OOD,ODG C OFRCERlh EXCLUDED? WC 023102424(WI) t,000;ODD (Mandatory in NH)u yes.descnbe render Continued on pdd'Ifmnal Page E L DISEASE-POLICY LIMIT 5 DESCRIPTION OF OPERATIONS Wow DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Addhlonal Remarks Schedule,may Oe attached IT"more apace is regldred) ' EVIDENCE OF INSURANCE CANCELLATION ' CERTIFICATE HOLDER HOME DEPOT USA INC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE " ROM PACES T USA,IROAO THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ATLANTA,GA 30339 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED RePREsewAnvE - of Marsh USA Inc. Manashi MukWee C 1988-2014 ACORD CORPORATION. All rights reserved ACORD 26(20141131) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: 100492 LOC#: Atlanta ACC ADDITIONAL REMARKS SCHEDULE Page 2 of 3 AGEN CY NAMED INSURED MARSH USA,INC. HOME DEPOT U.SA,INC. D1BIA THE HOME DEPOT POLICY NUMBER 2455 PACES FERRY ROAD BUILDING C•2D ATLANTA,GA 30339 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE Certificate Of Liability Insurance Workers Compensation Continued: Cartier:Indemnity Insurance Company of North America 1 Policy Number.WLR C49112294(AL AR,FL,ID,IA,KS,KY,LA,MS,MO,NE NM,ND,OK,SC,SD,WV,WY) Effective Date:03M12017 Expiration Date:03101018 (EL)Limit S1,I)D0,00D Cartier:New Hampshire Insurance Company Policy Number.WC 023102422(DC,DE,HI,IN,MD,MN,MT,NY,RI) EffecWe Data:031012017 Expiration Date:03MI2016 " (EL)Limit S1,000,000 Carrier:ACE American Insurance Company Policy Number.WCU C49112282(OSI)(AZ,CA,IL,NC,ORVA,WA) < Effective Date:031012017 Expiration Date:031012018 I (EL)Lunt S1,000,0M SIR$1,0D0,000 SIR for the states of Ara,CA,IL NC,OR VA WA Cartier.National Union Fire Insurance Company Policy Number.XWC 083144(OSI)(CO,CT,GA,ME.MI,NV,OH,PA,UT) Effective Date:031012017 Expiration Date:03MI2DI8 (EL)Limit$1.000.000 S1,000,000 SIR for the states of CO,ME,NV,+A,OKPA,UT S750,000 SIR for lheslete of GA S350,00D SIR for the state of CT „ Carrier.National Union Fire Insurance Company Policy Number.XWC 6583145(OSq(MA) I✓y Effect ve Dale:O'J0120i7 `' /1 ` Expiration Data:131012DI8 (EL)Unit 51,000,000 SIR SSDD,0M TX Employers XS Indemnity _ CarrierlUuiws Union Iraurance Company Policy Number.TNS C48613202(TX) Effective Date:03/012017 Expiration Date:CY0112018 (EL)Limit$10,000,000 SIR:S1,000,000 ` ACORD 101(2008101) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD t TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application # (�Z Health Division Date Issued P� Conservation Division Application Fee Planning Dept. . Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address 1Z )ywl Village Owner Address Telephone e J Permit Request Gf �« ` U fo�j DV Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation 0 0 `� Construction Type) Lot Size Grandfathered: ❑Yes ❑ No If yeFss dUY1YCwp3 Tg documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No Old K�FCighwa : ❑Yes ❑ No 9 9 9 9 Y 7� Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other n�OF BARNS—rA13LE 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 to If yes, site plan review# Current Use II Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name rtmD461A Telephone Number r 2 t5 r -Z4 AddressYk*&L Vl� License # 10 6 ,<7 It�J.kl1 Home Improvement Contractor# "/�56 Email Worker's Compensation # wo�,-o 0 q:221 6 6/ ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PR J CT WILL BE TAKEN TO Jk SIGNATURE DATE L FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED MAP/ PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL 'GAS: ROUGH FINAL •FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. • Massachusetts Department of Public Safety I I; Board of Building Regulations and Standards License: CS-100988 Construction Supervisor 4 HENRY E CASSIDY 8 SHED ROW WEST YARMOU�- H V� l� Expiration: Commissioner 11111/2017 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 153567 Type: Private Corporation Expiration: 12/15/2016 Tr# 259188 CAPE COD INSULATION, INC HENRY CASSIDY -- 18 REARDON CIRCLE SO, YARMOUTH, MA 02664 'Update Address and return card.Mark reason for change. 30n i {5 zoM•osi>> ElAddress El Renewal Employment Lost Card _------_ �e�voa�c��ao�racaecrlC/a�C�/T/lccnoaa/uaetta �\ Office of Consumer Affairs&Business Regulation License or registration valid for individul use only OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: egistration: �1.53567 Type: office of Consumer Affairs and Business Regulation ;j xpiratlon: :,;;12(15/20;1.6 Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 CAPE COD INSULATI'OK INC HENRY CASSIDY 18 REARDON CIRCLE` g SO, YARMOUTH, MA 02664 Undersecreta—ryry qN, valid 5signe The Commonwealth of Massachusetts A 0 - - Department of Industrial Accidents ... ........ t - ; Office of Investigations r,r 600 Washington Street Boston MA 02111 - ".,�__ www,mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leizibi Name (Business/Organization/Individual), I� Address, City/State/Zip; 40, to kOk b � Phone #; — Are you an employer? Check th appropriate box; 4, I am a eneral contractor and I Type of project (required); l.. .I am a employer with ��� _ ❑ g 6. New construction employees(full and/or part-time),* have hired the sub-contractors 2.❑ I am a sole h d h th or proprietor ro partner- listed on e attached sheet. 7, Remodeling p p p ❑ g shipand have no employees These sub-contractors have 8. (] Demolition working for me in any capacity. employees and have workers' comp, insurance.$ 9. ❑ Building addition [No workers' comp, insurance p• required.] 5. 7 We are a corporation and its 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work officers have exercised their 11.0 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.] / s *Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affiddvit 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 nbt those entities have employees. If the subcontractors 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: Y C(Gl�l C5 h 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 $1,500.00 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 insurarwd coverage verification. I do hereby certify d the pat an penalties of perjury that the information provided 4ovels ue and correct. aSi nature: �P Date: 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#, CAPECOD-27 BDELAWRENCE AFRO 716/30/2016 E(MMIDD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 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 BYTHEPOLICIES 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 pblicy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: RO , rs&Gray Insurance Agency,Inc. PHONE FAX 434 Rte 134 A/C No E t: A/c No): (877)816.2156 South Dennis,MA 02660 E-MAIL ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC p INSURER A:Peerless Insurance Company-see LIBERTY MUTUAL INSURED INSURERB:ATLANTIC CHARTER INSURANCE GROUP Cape Cod Insulation,Inc. INSURER c: 18 Reardon Circle INSURER D: South Yarmouth,MA 02664 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY 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. TYPE OF INSURANCE POLICY EFF POLICY EXP ILTR POLICY MM/DD/YYYYI (MMIDDIYYYYi LIMITS A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE a OCCUR CBP8263063 04/01/2015 04/01/2016 DAMAGE TO RENTE PREMISES(Ea occurrence $ 100,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 X POLICY JECT LOC ,. PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY , COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY Per accident $ AUTOS AUTOS ( ) NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ $ UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE I I ER B ANY PROPRIETOR/PARTNER/EXECUTIVE WCE00431901 06/30/2.015 06/30/2016 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If,yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Workers Compensation includes Officers or Proprietors. Additional Insured status is provided under the General Liability and Auto Liability when required by written contract or agreement with the Certificate Holder. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cape Cod Insulation,Inc THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 18 Reardon Circle ACCORDANCE WITH THE POLICY PROVISIONS. South Yarmouth,MA 02664 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION, All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD Town of Barnstable Regulatory Services �� Lticbard'V.scab,Director Building Division, Tom PerM Bt►H&M9 Commissioner r 200 Main Street,Hyannis.MA 02601 www.town.barnstabtemaas Office- 508-862-4018 Fax: 508-790-6230 - Propert# Owner Must Complete and Sign This Section If UsMI A Builder r, Alexandra Nowel as Owner afthe subject progeny hez+ebyaurhoiize C\,—. D to Cori —K1 to act on mybehalf, is all matters relative to authorized by this bw1d4 permit application for 72 Grove St., Hyannis, MA 02601 (Address,of Job) Pool fences and a] = are the responsibIty of the applicant. Pools are not to be filled or utized before fence is installed and all final inspecaons are performed and accepted_ 4. x - Signature o Signature of Applicant . x Alec"z&a- A4w-tC._ Pint Name Print Nam x Date 0-:r•0RMS:0wNMM;MWSI0N oois r fill- Town of Barnstabe *Permit# q, Expires 6 months from�isssue date Regulatory Services Fee BARNSMBM MASS. Thomas F.Geiler,Director prfp MP't� . Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma us Office: 508-862-4038 Fax:.508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY t Valid without Red X--Press Imprint Map/parcel Number Property Address ' A V Cep O 1 Residential Value of WorkWck,-IA, �SGz*3 Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address r7l.� 9 Telephone Nmber9�)a —LP Contractor's Name � 4 — Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable)2'Vorkman's Compensation Insurance X-PRESS PERMIT Che one: I am a sole proprietor APR - 8 2013 ❑ I am the Homeowner ( Ihave Worker's Compensation Insurance Insurance Company Name_� (dP�i1/`���p ' T����l-OF BARNSTABLE Workman's Comp.Policy Copy of Insurance Compliance Certificate must accompany each permit. Permit Requ (check box) Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) ❑ Re-side #of doors ❑ Replacement Windows/doors/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 u ed. SIGNATURE: nAT1TDV r rQVPr)1?X4q ,,,;Utina nesmit forms\EXPRESS.doC The Commonwealth wearlth a,f assachusetts Dejmrhnent of ludxr &ial_4cddenft Office of Invesfigalions 600 WashhVton Street Boston Md#23I1 . www..ma smgvv/dia Workers' Compensafian Insurance affidavit BuilderslContractorslElectric anslPhmbers A pficant Informatian ` q Please.Print Ledhl— Name Musj ti &7iduai): t Yt Address: �'�,go,.-ze City/Statel4-p: 1 pf Phone#: C a?y� Are you pIo er? Check the appropriate box - Type of project(required): . ❑ I am.a general contractor and I 1. atn a employer with 6_ ❑New construction employees(full aaadlor pat-b=)—* have wed the sub-contractors 2.❑ I am a sole pmpriebar orpartner- listed on the attached sheet 7. ❑Remodeling ship and have no employees `these sub-contractors heave g_ ❑Demolition w ina for me in any capacity. employees and have wwkers' g. ❑Building additiag [No wod=s' comp-insurance comp-menrMMI required-] 5. ❑ We are a corpom-ion.atad its 10. Electrical repairs or additions 3.❑ I am a homeowner doing all woFlS officers have exercised their i l_❑Plumbing repairs or additions myseS£[No workers'comp > of exemption per hfC�L 12.0 Roof repairs insurance required.]T c.152,$1(4# and we have no ] t 13.0 Outer employees- workers' yam- comp.insurance requirexl.] *Any apphcu that checks box 91 also ffil oat th,e section below showing their wu&exs'compensation policy ud=mv is I homeowners who submit this at3dsvit indicating they asedo=g all work sad then ham outside coutr%=n nmst submit a new affidavit indicating such tContr crm that check this boot mast attachmd an additional sheet showing the mane of the sob-cmArsctoss and state whetitier ar not-dose entities bare emp3avem.Ifthe s -cQntaaciars have employees,iheYMmmPxovide tax markers'comp.policy number- if atn aaa sltnpir��r tlra#ispt�ovidizag tvt2r#err'co>r�saasrrfio+t iru�rrarace for aiy's�F�3` B�eaToty is firs ps�ticy�aatd jab site ixfort�trrlian. /- - Insurance Company dame: Policy 9 Cr Sel€iris.Lic.# 7P,9 yg�3�`P�%4 ��i Expiration Date: r3 Job Site Address: ,�� � JZ>� % y/hzt G1/ CityfStater4: Attach a copy of the workers'compensation policy declaration page(showing the Policy er and elation date). Failure to secure coverage as required under Section.?-5A of MGL c- 152 can lead to the imposition of criminal penalties of a fine up to S 1,500 00 andfor one-year imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to tine Office of faves4gations of the DIA for insurance coverage verifcatim T do haraby COY* tkrpa f s rl peata�es gfperjwy that&0 inforawaa w'"prrtt�ixfed above rs bare r1�rd carrot Si hate_ Phone ©gavial xsa only. Do not write in this area,fobs completed by city or town$oaf . Utyar*Town- Permiblacense At ]ssuiug Anthority(ci rde one): . 1..Board:of Health 2.Building Department 3.CityII own Clerk 4.Electrical lnspeetor. S.P1. imbFrg Inspector _ . . . .. _ :.. . . . . : .. phone#: . P�pF THE Tp�� * seRxsrABM • 059: Town of Barnstable ATED MA't a Regulatory Services Thomas F. Geiler,Director. Building Division Thomas Perry, CBO Building Commissioner 200 Main-Street,, Hyannis,MA 02601 www.town.barnstable.mi.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder �-A �,�l%�/ ;as Owner of the subject'property hereby authorize ,( i> �JS to act on my behalf, in all matters relative to work authorized by this building permit application for: 1 (Address o ob) Signature of Owner a e Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on.the reverse side. \WPHLESTORMSftildin Q: g Permit formslEXPRESS.doc °FVE Town of Barnstable p� Regulatory Services BARNSTABLE, ' Thomas F.Geiler,Director Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.m.a.us Office:. 508-86 2-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village . "HOMEOWNER": name home phone# work phone# CURRENT.MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to be,a one or two- family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who-constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws, rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and.requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official containing 35 000 cubic feet or larger will be required to comply with the State Building Code dwellings co 9 Three-family dw g Note: Three g . Y g 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,at 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. �► CER71Ft ATE OF UAB1LJTaf INSURANCE " I °"`�`•"° 9 3/12 TM.C 7E--B�M A Y�DF 01t Ot<T/lid ND SIM cm bow'. T/pR—.P.0 .Y OR MUMMY AilBW�EXTE D Clt/�.'�TIE OpY8016E Alm 9Y THE!i. i 7H3 -� DOFFS IiDT C NfffFn =A C0KMW'F TfE i N • MODUCHL NPO MM. ■�ee 6s hailer is ffii �p nastl�e d. l5 Bet s:ad oaodi�as afBe poidyG oe poisiwmw am eado A Am"ls a adoanfer is - oert�f00oideri�tl�afsnd� - " Chagnon Insane Jkgenc!Y, Tr^- 508 771—i66fl � PO Harz 355 411 Resits 28 a West"Yazmauth, UK 02673 A:Tzaveleas MmAuraom gum David S.-.Hodsdoa, II tee- _ DHA Hodsdon Cons PO How 221usuFatm Ya�aothpoaa, ffi 02675 pp :. CmCATENIliINm REVOW ES1ED7i0THEABDVEPO:iC1f IMASIOCEFO sY7HNTIMFO.IM JCE iSnMEEtAWH&VESEM Ef _M8f T,19i11 aROOHt1 AMf BtC2 RFRC lTE MAY BE OR MW PEKO THE 6Y?tE PELIQi35iS 11D AiL'i1BEXMUW6AWCb fn=0FSUM- UL==YI NffHAVENM WPl1D e�taeamr . . s pAl�FtiATJE oo�t - pED� - s PERSOWAA W s : same. s -GEMtAGMaMTEuwAPPmpm t+ ass- ass s muctt Quo - s s E!_mO.Youwww s ANYA= ALLOW" SCHEDUM AS1 BpDAYdii1RY�Aet S s HMAUM —Burros s smoc tajatA= oawa r s oai AeGlEem s I cm g -#PJ Bd321P40Al2 7/29/32 7/29M g teICBDCpr- A1rD 'lIR6•ilT YiN i 100 QQQ Nla s 100 000 N°O°ga=aP�a • uar s 300 ,000 oF ►t�or�moNsiveeass(ammaco�s».as���e*m.a4.m.�+�uaV 1Y operations, iatesaoac_.a eaterios iS2::fa®i].y ha®es: 6 private gages (=79 W-HOLWR - - CAliCf3.LATlON p.DAff4Wl EAWYE BECARCBLED W-'ESR. "M DAA TiElEOF, R N ya=mthAO lAR1H PO 'YPRCd�B- Saath Ya=outh, MA 02654 AWOMaM ®19f8,2<1'IAACDRDWL Ma -ft f ACM 25PN81 M Tim ACC oamo and logo we i &te P 'wnavftofl=RD - _ PhD= FCC E 3616 Massachusetts-Department of Public Safety Board of Building Regul:[tirsns and Standards _;'-:!s ,y CS DAM S }IODSDOAI 11 1 M BOX ni ; YARMOUfHPORT N1A OW5 Expiration: SMIM3 f'�mmitinner` TT#. ism F HOME OPROVEOWCONTRACTOR Type= err: 105172 Win: DRA E �- , 14 CAR AS David Hodadon li s -_-=� ` Dr in Yarmouth Pat.MA -' ; ` Underie"veNT II - Map Page 1 of 1 Town of Barnstable Geographic Information System New Search I Home I Help Parcel Viewer Custom Map Abutters Map Size ® Zoom Out I I j ,in 7PG Map: 309 Parcel: 074 FulA Property e R ,1 P rtY Location: 37 PINE COURT Info N85 £ —182 31g14B� 'j `.�" `, I84 Owner: MILLER,HEATHER t� Location Information Map&Parcel 309074 Location 37 PINE COURT z f Acreage 0.18 acres Ah ✓ �, 3genag Current Owner = Mailing Address MILLER,HEATHER ✓ �° r 112 WAYLAND ROAD HYANNIS,MA 02601 '. Appraised Value(FY 2014) Extra Features $0 s } 30907a `m Out Buildings $0 N 37 Land $5,100 Buildings $0 Total A PPraised $5,100 309075 Assessed Value(FY 2014) s Extra Features $0 � ,T a - 309078 Out Build 3 72 ings $0 b ,#`' 309077 N42 '�;$ Land $5,100 Buildings $0 Total Assessed $5,100 Set Scale 1"=40 __..' April 2008 n� 11,- MAP DISCLAIMER Copyright 2005.2010 Town of Barnstable,MA All rights reserved.Send questions or comments to G I S BarnstableMA V1.2.5122 [Production] http://66.203.95.236/arcims/appgeoapp/map.aspx?propertyID=30... 1/10/2014 Town of Barnstable *Permit# Expires 6 months from issue date Regulatory Services Fee �� i IMMNSMM MA $ Thomas F.Geiler,Director 039. �0 pTfD MP't A. . Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town barnstable.ma.us Office: 508-862-403 8 Fax:-508-790-6230 EXPRESS PERNHT APPLICATION - RESIDENTIAL ONLY c���Not Valid without Red X--Press Imprint Map/parcel Number �l Property Address � ���Q D yt OJTH —y-,l 5'gyp 02 C ao i ❑Residential Value of Work— �� Minimum fee of$35.00 for work under$6000.00 LW- �i j Owner's Name&AddreS__S_— (20 Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) PRESS Construction Supervisor's License#(if applicable) X- IT ❑Workman's Compensation Insurance MAY 12 2013 Check one: �❑ Iaam a sole proprietor aqi the Homeowner TOWN OF BARNSTABLE ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) Re-side 1 #of doors # ❑ Replacement Windows/doors/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 quired. SIGNATURE: 3 �V v r The Commonwealth ref Massachusetts De, arbnent of Industrial Accidenft _ - - t✓ Offic o, InvestigrYfions 600 Washington Street' Boston,M4 0111 . rvmv wars gow/dia Workers' Compensation Insurance Affidavit: BuddersfContractorsMecfric ansfPhulmbers Applicant Information Please Print Legilh A dress: CityfStatefZip.: V)Y) Phone 4 Are you an employer?Che-A the appropriate bds Type of project r 4. I aas.a contractor and I YP P 7 (required): 1.❑ I am a employer with Feral . 6. New cant.-wtion employees(W andfor part-time)_ have hired the sub-contractors J❑ I am a sole proprietor:or partner- listed on.the attached street. 7. ❑Remodeling ship.and have no employees 'These sub-contractors hmm g- ❑Demolitioa w g for Il3e iTl a employees and have wa&ers' o nY sty X ❑Building addition N0 workers*comp.insurance quired.] 5. We are a corporation audits 1 t}.❑Electrical repairs or additions re :f&i homsowaer doing all work officers have exercised their I LE]Plumbing repairs or addition myself o workers' right of exemption per 1YfGL my [No comp- 12.0 Roof repairs, insurance required]T• c.152,§1(4�and we have no 131-1 Other employees-(No worms' comp.iusaraom required.] `Any applicain that checks bog#1 mast also filloat the seclion below show mg thesworkea'ca pensabon-policy iffmxasvam- Y Homeownem wbo submit this amdavd im&rx++ng they am data$sH wit mad them hire outside camtmctms mast submit anew affidavit wdic Mg such tCantraciors ifLvt check this beet must attached an additional sheet showing the usme of the sub-coatractm and stale whether or not those entities have empkmees. iftbe sabtonttamis have employ,they—tpmvide theu wmrke&comp.policy number- I aunt azt emplo�,sr thatis providraig_workers'cote muation irrsurimce for uty etrrplo3 Bda v is thepaUgr acrid job site irrforrrtrcte�rr. . h u-ace Company Name: Policy-or Self-ins-Lie. Expiration Date: Job Site Addiess: GitylStatefZp: Attach a copy of the workers'compensation policy declaration page(showing the policy number and espimtion date). Failure to secure coverage as required under Section 25A of MGL c- 152 can lead to the imposition of criminal penalties of a fine up to S 1,500_00 aadfor one-year imprisonment,as w+eT1 as civil penalties in the fbfm of a STOP WORK ORDER and a fine of up to$250-00 a day against the violatar. Be advised that a copy of this skitementmay be forwarded to the Office of IrrmskigabLow of DIA for inm*rmce coverage ver fitation- ' i do hereby certify under thepaiks andpenaMes ofpedk7 that the inf4?rmd&n pivi4ded ahave is.true'arid correct r ©,dal um only. Do not write in this arm,to be compWod by city or town ofeiaL . Utyor*Town: permit lUcense# fssuang Aufhoiitp(tdrde one): 1..Board.of Health 2.BuRdintg Departtuent 3. f ro asn Clerk' d.Electrical Inspector 5.Pt=biag Inspector .6.Other.. phone#: . ti. �oFIME Town of Barnstable Regulatory Services RARNSTABLFE Thomas F.Geiler,Director MAss. 9`l'ArE%639. `�� Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office:. 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE• I , JOB LOCATION. number street, , ,_ �r— ageY _a KA"HOMEOWNER ;� name home phone# work phone# CURRENT M'AILIXG-ADDRESS--�- r .2 ' A_ Yl. _ty/town„� state zip.-code------*.T'� The current exemption for"homeowners"was extended to include owner-occupied dwellings of six u nits 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 OFHOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is, or is intended to be, a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall-.not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws, rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection du �drequirements and a/she will comply with said procedures and requirements. Sign_ atu`re of Homeowner ""s' 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. . . r s�xxsrast.E. � . 659. ,� Town of Barnstable .. ArED MAt a Regulatory Services Thomas F. Geiler,Director. Building Division Thomas Perry,CBO Building Commissioner 200 Main.Street, Hyannis,MA 02601 www.town.barnstable.mi.us Office: 508-862-4038 Fax: 508-790-6230 Property Own Must Complete and Si This Section If Using Builder as Owner of the subject property hereby authorize to act on my behalf, in.all matters relative to work authorize by this building permit application for: ( dress of Job) Signature of Owner Date Print Name If Property Owner supplying for permit,please complete the Homeowners License Exemption Form on;the reverse side. Q:IWHILESTORMSIbuilding permit formslEXPRESS.doc _ . THE The Town of Barnstable 9� ""' . z63 q Growth Management Department �0 CEO�A0�� 367 Main Street Hyannis,MA 02601 Office:508-8624678 Fax:508-8624782 September 30,2005 Mr.John C.Klimm,Town Manager GaryR-Brown,Town Council President Barnstable Town Hall 367 Main Street Hyannis,MA 02601 Re: Janet Van Orden— 1005 Old Stage Road, Centerville- a single-family accessory unit o 3 Tom Hughes,Safe Harbor Real Estate,LLC-72 Grove Street,Hyannis - a single-family accessory unit Gentlemen: This letter is to inform you that the Accessory Affordable Housing (Amnesty] Program has received requests for project eligibility letters under the Community Development Block Grant (CDBG) Fund and under Article II of Chapter Nine of the Code of the Town of Barnstable and the criteria for the Local Chapter 40B Program This office is reviewing the requests.If the Town has any comments on the projects,please forward them to me so that they can be addressed in the site approval letter. This letter gives you official notice of our receipt of the above application(s). We will issue a decision as to the acceptability of the sites and the consistency of this development within the guidelines of CDBG. Sincerely, i Elizabeth Dillen Special Projects Coordinator Growth Management Department cc: Town Attorney's Office/. Building Department Public Health Department i R Town of Barnstable FTHE 1pk, Regulatory Services t Thomas F.Geller,Director B" Building Division Z MASS. 9 AS3. 0a i639. ♦0 i°tE M Tom Perry Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 Fax: 508-790-6230 COMPLAINUINOUIRY REPORT Date: Rec'd by: Complaint Name: Map/Parcel Location . Address: Originator Name: Street: Village: State: Zip: Telephone;, Complaint Description Je �� OFiFICE UM ONLY Inspector's Action/Comments Inspector: Additional Info.Attached Q:forms:complaint I 6/19/03 = , - 72 Grove Hy 61 t �:�. ,_ �, � � • Bpi �. 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