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Assessors offioe,'(1st floor):. /
'Asses'. is map,and lot number` ..... .. ......D�,�-" o% ` ram �F7NET0�♦
Board of Health.(3rd floor):
Sewage Permit number
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Engirieering. Department (3rd floor): ""0`
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House number :................ :.....:........y�..;. v. Y aye
„' �j liG �O MA
APPEICATIONS PROCESSED 8:30'` 9:30 A.M. ,and 1:00.2:00-P.M. only,
TOWN "�OF, BARNSTABLE '
BUILDING ' INSPECTOR ,
APPLICATION 'FOR 'PERMIT TO ,.;•„�rv^!..........................................
TYPE OF: CONSTRUCTION ... �w6-C •...: .. L• ? /''`��
�/........�✓e
................................'- 19........
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a-permit according to the following information:
2[ /llr�C y�n.su..fl '
Location .......................................f....................................... ...... .................................................................y............................
�..
Proposed Use St�G-C ............................................................ .........`
..........................Fire District °Zoning District ............................................. .............:................................................................
Name of Owner Gitc2 d✓�42I E�. �0(�. Address .. ........ ..r!X:..S I bi......................
Name of Builder ;�
...............::...:..........:............ ......................_Address ................................ ...................................................
Name of Architect .....................................................................Address ..........................
Number of Rooms ...................................................................Foundation ...... ovrZ Oo..iedt..-c-r..
Exterior .........!C ....:......1n..F.L;.3.r..e........... .....Roofing .:.........4 S,D.rU�C 9"........................................................
Floors f° �V1.^!. ....:...................::.....:......Interior ..........�dJc� �,L'd. �............................................... ....
Heating ..........A.>.. . ...., ins .............:.... ........Plumbing ................/..'f....................................... ..............:
A15
Fireplace ......... !. .......................... ......................................Approximate Cost..... ..;................:..........::.............:'. ............
Definitive Plan Approved by Planning Board -------- ___ __/___-----------19 K. Area ......... ..... '. ..
Diagram of'Lot and Building'with Dimensions Fee .�
...............................
SUBJECT TO`APPROVAL OF BOARD OF HEALTH
t
I
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS i
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Name ... ... ................................
`f Construction Supervisor's License ..." ....... ...................
GREENBRIER CORP. _
} No'� 33116 'Permit for 1 z StorX............
..Single Family...Dwelling......
......
,Location ••••. 41...Ki1•kore Drive
... �.
i
.. s.................... .....
Owner ....G.re.e.nbrier..Cor ... .... .. ................ ........ .......... -
a.
� r
Type of Construction ...'.Frame _•
................................. r
,J ........................................................... .................. .G' , ' ^ I .,.f- ti • r. / c--- -•>�
Plot .. ......... .... Lot ............................
Permit Granted ......Ai.dguat...3..............19 89 '
• Date of Inspection .....19
Bate Completed ... .....c 7� ..... :19/ s R
' y
1
THE Town of Barnstable -' *Permit#
1° 'b Expires 6 mon hs jrom issue date
Regulatory Services Fee
Thomas F.Geiler,Director
TO �Ar1 ► 08 Building Division
Tom Perry,CBO, Building Commissioner
NSTABLE 200 Main Street,Hyannis,MA 02601
www.town.bamstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY
Not Valid without Red X-Press Imprint
Map/parcel Number
Property Address ` ( Ki 1Ko�re
❑Residential Value ofWork Minimum fee of$25.00 for work under$6000.00
'
Owner's Name&Address J oo—k cq
Contractor's Name Telephone Number
Home Improvement Contractor License#(if applicable)
❑Workman's Compensation Insurance
Check one: -
Elam a sole proprietor
-
hVam the Homeowner
❑ I have Worker's Compensation Insurance
Insurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must be on file.
Permit Request(check box)
E2 Ke-roof(stripping old shingles) All construction debris will be taken to �ex J
❑ Re-roof(not stripping. Going over existing layers of roof)
❑ Re side
❑ Replacement Windows/doors/sliders.U-Value (maximum JV4•�`�
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License is required.
SIGNATURE: 0
qKMj
Q:\WPFILESTORMS\building permit forms\EXPRESS.doc
Revise020108
�eq
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 Ledbly
Name(Business/Organization/fndividua): iJbi 13t �� ��na�SQYI
Address: 4� 'I
city/state/zip: 10.hn N dNll'�: C��t90 1 Phone.#:SU?S %(9a'C51
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
. . employees(full and/or part-time).* have hired the stab-contractors
2.❑ I am a'ole proprietor or partner- listed on the attached sheet 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me inany capacity. employees and have workers 9 ❑guild�ng addition
[No workers' comp.-insurance, comp.insurance.#
• ed.J 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.91 am a homeowner doing all work officers have exercised their It.❑Plumbing repairs or additions
myselL[No workers' comp. right 6f 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 Homeowner;who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
IContraetors that check this box must attached an additional sheet showing the name of the sub-conbactors and state whether or not those entities have
employees. If the sub-contractors have employees,they must providb 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.M 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 tip 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
Investieations of the MA for insurance coverage verification. -
I do her jy under the ains-and�peQQna��lties of perjury that the information provided above is true and correct
Si atur ll�x.U- Date:
�yLAPhone k _
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 hue,
express or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced-acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states`Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for,the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants - -
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies'(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit ono 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 born 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 C6mmonwealth of Massachusetts
Dgwtment of Industrial Accidents
Office of Investigations
600 WashinPn Street
Boston, MA 02111
W. #617-727-490..0 ext 4-06 Qr 1-977-MASSAFE
Fax# 617-727-7749
Revised 11-22-06'
www.mass.gov/dia
r
SINE► Town of Barnstable
Regulatory Services
BARNszABLE• Thomas F.Geiler,Director ,
16 9 Building Division
Tom Perry,Building Commissioner.
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-8624038 Fax: 508-790-6230
Property Owner Must
,Complete and Sign This Section,
If Using A Builder
as Owner'of the subject property
hereby authorize to act on my behalf,
in all matters relative to work authorized by this building permit application for:
(Address of Job)
Signature of Owner Date
Print Name
If Property Owner is applying for permit please complete the
Homeowners License Exemption Form on the reverse side.
QTORM&OWNERPERMISSION
Town of Barnstable
�OFIKE Tp{yti
Regulatory Services
+ BARNSfABI.E,
Thomas F.Geiler,Director
9 MA99. g
1 39. s.• Building Division
TfD � Tom Perry,Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.barnstable.ma.us
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE:
JOB LOCATION:
number street village C
•.HOMEOWNER": 1)Ixn� k\�Y)o u 1 6n ILQ�lvD 1 - t1% 9 91�JI,
name , ` {�hom�e phone# work phone#
CURRENT MAILING ADDRESS: `Ltk I�fN e. DJ`A u—q—
ti40,nV\*I 5 Mal W,6c�
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
7ements.
Signature of Homeowner
Approval of Building Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the
State Building Code Section 127.0 Construction Control.
HOMEOWNER'S EXEMPTION
The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions
of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a person(s)for hire to do such
work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor(see Appendix Q,
Rules&Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often results in serious problems,particularly
when the homeowner hires unlicensed persons. In this case,our Board cannot proceed against the unlicensed person as it would with a licensed
Supervisor. The homeowner acting as Supervisor is ultimately responsible.
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the permit application,
that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page of this issue is a form currently used by
several towns. You may care t amend and adopt such a form/certification for use in your community.
Q:forms:homeexempt
. r Town of Barnstable Building
t��^ �• " ' Y .. ,. \ ,;; � �
Post This CardTSo.That itis Vis�bleFromthe Street��A rovetlSPlans IVlust'le.Retaned;onlo6;and this Card Must beKe't
* ana�va;ewec s nrf P
_ J"*J
Posted Until F�nal,lnspection Has BeenMade a ¢ ti ky �? 3�
163P a r
r+ +° Whe e�a Certifci ate f ..: k, .. t ed y _ ..<,. '. Permit
1111t
.,mmF :go Occupancy isReq ,such Buldmg shlltbe Occ upieduntil a:F�nal coon has bmeen madeE.
Permit No. B-18-1403 Applicant Name: ALTERNATIVE WEATHERIZATION, INC. Approvals
Date Issued: OS/29/2018 Current Use: Structure
Permit Type: Building-Insulation-Residential Expiration Date: 11/29/2018 Foundation:
Location: 41 KILKORE DRIVE, HYANNIS � Map/Lot: 272-OOS 012 Zoning District: RC-1 Sheathing:
Owner on Record: DONALSON, DOROTHY CoritractoKNa e ,ALTERNATIVE WEATHERIZATION, Framing: 1
Address: 41 KILKORE DRIVE ZINC
2
HYANNIS, MA 02601 a Gontractor�1i66nse 7 683
' Chimney:
Description: Weatherization ESt Project Cost: $2,776.00
Insulation:
Permit�Fee: $85.00
Project Review Req: '
Fee Pard: $85.00 Final:
�a Dates 5/29/2018
R _. . _ . Plumbing/Gas
Rough Plumbing:
o
Final Plumbing:
y, Building Official
Rough Gas:
This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after"issuance.
� Final Gas:
All work authorized by this permit shall conform to the approved application and the approved construction documents,for which this permit has been granted.
All construction,alterations and changes of use of any building and structures shall be in compliance with the local zornng by laws�arid codes.
This permit shall be displayed in a location clearly visible from access street o road and shall�be maintained open forW.public�mspection for the entire duration of the Electrical
work until the completion of the same.
Service:
The Certificate of Occupancy will not be issued until all applicable signatures by the Bui ding aril Fire Officis�are provided,.on this permit. Rough:
Minimum of Five Call Inspections Required for All Construction Work: - Y" g
1.Foundation or Footing Final:
2.Sheathing Inspection
3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Low Voltage Rough:
4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection
5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Final:
6.Insulation
7.Final Inspection before Occupancy Health
Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Final:
Work shall not proceed until the Inspector has approved the various stages of construction. Fire Department
"Pe ons co acting 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
c All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT
r Qi► Application Number..............................................................
00
MAS& rmit fee; .,:...: '.................Other Fee......,,.....,.,;.......
039,
AY 0
2q Total Fee Pail............... . ........ ................ ....
,.
TOWN Of BARNSTABLE fPgfm,t;Approvalby:.. ....:.................:.....,�n:.:.. .,....,
BUILDING PERMIT
Map...,.—_..............................Parcel.....,,........
APPLICATION
Sectionl Own' er's nforinrmat on any Projeet L€ieat on
Project Address �t t, `'�! 1 I Q _ �. Village �$
Owners Name &
=Owners Legal Address ,o
uCiry S State klA zip , bclUd0 1
;Owners Cell _ '1116 Vi!-6 11 E-mail dr-
Section 2 — Use of Structure
Use Group ] . Commercial Structure over 35,000 cubic feet
Commercial Structure under 35,000 cubic feet
Single!.Two Family Dwelling
Section 3--Type of Perr>l i
New Construction ] Move 1 Relocate ❑ Accessory Structure ❑ Change of use
Demo/(entire structure) Finish Basement R Family/Amnesty Fire Alarm
Rebuild [� Deck Apartment Sprinkler System
Addition Q Retaining wall [] Solar
Renovation 0 Pool ❑ Insulation
other—Specify
Section 4 - Work Description
S 4i6 �o use
Last updated.3/1-5/2018
f
Application.Number....... ..........................................
Section 5—Detail
Cost of Proposed Construction 77(�11) Square Footage of Project
Age of Structure Dig Safe Number
# Of Bedrooms Existing Total#Of Bedrooms(proposed)
l 10 MPH Wind Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist Design
Section b—Project Specifics
❑ Wiring ❑ Oil Tank Storage Smoke Detectors
❑ 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: I am using a crane ❑ Yes ❑ No
Section 7—Flood Zone
Flood Zone Designation
Within or adjacent to a wetland,coastal bank? Yes ❑ No ❑
Section S--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
Has this property had relief from the Zoning Board in the past? ❑ Yes ❑ No
Last updated:3/15/2018
Application Number............................................
Section 9--Construction Supervisor
Name %i1'li5Telephone Number Vb
Address_49 City State Zip a ---
License Number I65��� License Type Expiration Date 67ellv --
Contractors Email _aJY407 4,?9Ve- Cell #
l v✓1 Cd '
I understand my responsibilities under the"ru s and regulations for Licensed Construction Supervisor in accordance with 780
CMR the Massachusetts t 'Building Code. I understand the construction inspection procedures,specific inspections and
documentation require CM a' 'th To f Barnstable..Attach a copy of your license,
Signature Date J�
Section 10—Home Improvement Contractor
Name A"kt44.f"wf_ U)�.JA II elephone Number
Address
v2 � t City"Pat/ State_/M ZipQ /
Registration Number_/7�Q —Expiration Date_ Ql 9
I understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780
CMR the Massachusetts State Building ode. l nderstand the construction;inspection procedures,specific inspections and
documentation requi y 780 C an the o no.f Barnstable. Attach a copy of yourH.I.C...
Signature V Date
Section 11 —Home Owners License Exemption
Home Owners Name:
Telephone Number Cell or Work Number
I understand my responsibilities under the rules and regulations for Licensed_Construction Supervisor in accordance with 780
CMR the Massachusetts State Building Code. "I understand the construction inspection procedures,specific inspections and
documentation required by 780 CMR and the Town of Barnstable.
Signature Date
APPLWAJT SIGl� TUR
Signature Date 5
Print Name TM Telephone Number
E-mail permit to: Gt,l�P�i�c�iy�-t� i�i za •�'l C� �• cy��
Last updated:3/15/2018
Section 12 —Department Sign-Offs
Health Department 01 Zoning Board (if required)
Historic District Site Plan Review(if required)
Fire Department ❑
Conservation
For commercial work,please take your plans directly to there department for or approval.
Section 13— Owner's Authorization
as Owner of the subject property hereby
authorize 17 r to act on my behalf, in all
matters relative to work auth rized by this building permit application for:
r^
(Address of job)
Signature of Owner date
Print Name
Last updated:3/15/2018
APR/26/2018/THU 12: 14 PM CCH OB/GYN PAX No. 7745526962 P. 003
I"E.ra Town of Barnstable
0
Regulatory Services
sAWSUllM + Richard V.Sc4 Director
'MASS.
Building Division
Paul Roma
Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ina.us
Office: 508-862-4038 Fag: 508-790-6230
Property Owner Must
Complete and Sign This Section
Y, DOROTHY R DONALSON , as Owner of the subject property
hereby authorize to act on my behalf,
in all matters relative to work authorized by this building permit application for:
41 Kilkore Drive Hyannis, MA 02601
(Address of Job)
*C�of
e r Date
eD ��4
Print Name
If Property Owner is applying for permit,please complete the Homeowners License Exemption Form.
C:\Users\dewff&\AppData\1.owwicrosoR\Windows\]NetCache\Comenc.OWooML7U69L*F2SXPRESS(2).doe
01/25/17
The Commonwealth of Massachusetts
Department of Industrial Accidents
a 1 Congress Street, Suite 100
Boston, MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Indiiidual):ALTERNATIVE WEATHERIZATION, INC.
Address:2 LARK STREET
City/State/Zip:FALL RIVER, MA 02721 Phone#:508-567-4240
Are you an employer?Check the appropriate box:
Type of project(required):
l.�✓ I am a employer with 16 employees(full and/or part-time).* 7. ❑New construction
I am a sole proprietor or partnership and have no employees working for me in
8. EJ Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.[]I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 E] Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees. 12. Plumbing repairs or additions
5.M I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs
These sub-contractors have employees and have workers'comp.insurance.$ p
14. Other
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c.
❑✓
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
+Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
*Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:STAR INSURANCE COMPANY
Policy#or Self-ins.Lic.#:0849257 00 Expiration Date:4/4/10
Job Site Address:/ A�j
G„�� YP City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy nu er and ex ration 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 S250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the D1A for insurance
coverage verification.
I do hereby certify under t e pains and pen es of jury that the information provided above is true and correct.
Signature: Date:
Phone#:508-567-42 0
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#:
ALTEWEA-01 SNERONHA
AC`C7►!?L3'` DATE(MMWIYYYY)
CERTIFICATE OF LIABILITY INSURANCE 0312312018
! THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS j
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSORER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: if the certificate holder Is an ADDITIONAL INSURED,the policy(les)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION IS WAIVED, subject to the terns and conditions of the policy,certain policies may require an endorsert)ent, A statement on
this certificate does not confer rights to the certificate holder In lieu of such endorsement s.
PRODUCER ACT Christine Cosh f
Mason&Mason Insurance Agency,Inc. HONE >d JAIC,No,E :(7i31)447-6531 ,ko):(789)447-7230
4b8man, Ave. i CCt)8ta masoninsure,Com I
Whitman,MA 02382
ass:��
INSURERt3I AFFORDING COVERAGE NAICH
I INSURER A:Evanston Insurance Co. 135378
INSURED Pa_-sUstEre a:Safety Indemnity _ 33618
Alternative Weatherization,Inc. ;aasURER c:Star insurance Company I18023
2 Lark Street INSURER D: l
Fall River,MA 02721 -""-
INSURER E:
1
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.
INSRj ADDL,+SUBR OUCYEFF P POLICY i ---_ l
LTR TYPE OF INSURANCE i POLICY NUMBER UMITS
A i X !
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE S 1,000,00fl
I DAMAGE TO RENTED
CLAWS-MADE OCCUR X X 3C420$$ 0610712017 10610712018'PREMIs£s(Ea accurreTce) i s 10fl,00fl
_
— —_
l MED EXP(Any one person) Is 6,000
I I ?PERSONAL 8 ADV INJURY i S 1,000,000:
�._.._ _..__..._._._ 2,OQ0,0fl0
i GEN'L AGGREGATE LIMIT APPi.iES PER: i i ?GENERAL.AGGREGATE S _ 1
I X !POLICY — j LOC PRODUCTS-COMPIOPAGG $ 2,Q{�fl,flafll
_j
c
OTH R. I COMBINED SINGLE LIMIT s fl0
B AUTOMOBILE LIABILITY S 1, 0,000
ANY AUTO X 16237702 '0410812018I0410812019I BODILY INJURY(Per persori s
OWNED X SCHEDULED
i AUTOS ONLY , AUTOS I ! BODILY INJURY{Per atcit)eni) S
X I H)R�p X I NON.pp��NNtD j PReOPERTQ DAMAGE 5 ——�
AUTLISONLY ALlrOS�ONLY , P�
it f`_ }
I
i I S
A _ UMBRELLA LIAR' f X OCCUR I EACH OCCURRENCE g 1,000,000�
X EXCESS UAS i CLAIMS-MADE X X j OBW7126S17 06/07/2017(06107/20181 AGGREGATE Is 1'000'000s
DED (RETENTIONS
C WORKERS COMPENSATION LIABILITY YIN i 4421 040fl1jANY PROPRIETORPARTNEREXECUTIVE W
E.L.EACH ACCIDENT is 600.000:
OFfiCERR1M8€,R EXCLUDED? i N 3 3 N 1 A I
(Mandatory m ) ( i E.L.DISEASE-EA EMPLOYEE(S 50fl,Oflfl'
i 13I yes,descrlDe tattler i I —
DESCRIPTION OF OPERATIONS below i E.L.DISEASE-POLICY LIMIT 'S
l i
1 +
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks SctWule,may be attached It more space is required) ]
:Action Inc.and NGRID USA,its direct and indirect parents,subsidiaries and afflliates is added as an Additional Insured for General Liability on a Primary&.
;Noncontributory basis per the terms and conditions of form CG2001(04/13),for Ongoing Operations per the terms and conditions of form CG2010(04113),for I
Completed Operations per the terms and conditions of form CO2037(04113)and Waiver of Subrogation applies per the terms and conditions of form
MEGL0241-01(04.11).
;Additional Insured for Automobile Liability applies per the terms and conditions of form SCA005(02/16).
i
!Excess Liability is a following form,
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
j THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
NGRID USA ACCORDANCE WITH THE POLICY PROVISIONS.
40 Sylvan Road
Waltham,MA 02451 l
}AUTHORIZED REPRESENTATIVE
III rL_.
ACORD 25(2016103) @ 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
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34
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Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Ma�chusetts 02116
Horne Improveme4iDontractor Registration
f Type: Corporation
r $ Registration: 175683
ALTERNATIVE WEATHERIZATION,INC.
iraiion: {}512812019
2 LARK ST .
FALL RIVER,MA 02721 `
c
.4 �, s"
Update Address and return card. Mark reason for change,
.Acldre ,��.a�a�ra1...CI.IW�nl�vm�nt I-I I ect. a
- -W Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for Individual use only
' TYPE:Conooration before the expiration bate. If found return to:
8jW attI*n 9xWmtIon Office of Consumer Affairs and Business Regulation ,
s27 05M/2019 10 Park Plaza-Suite 5170
ALTERNATIVE WEAT-iEPJZATION,INC. n,MA 02116
TIMOTHY CABRAL
2 LARK ST _
FALL RIVER,MA 02721 Undersecretary of Yt 0 v ou Si 81r�.
ALTERNATIVE
WEATHERIZATION
Date
Town of Barnstable
200 Main St
Hyannis,MA 02660011
Re: Permit#!-' L 3
The insulation work.at_ QiS �� _��S /�� /`�/�• / �e�s�
Agency work performed fO /
Regan .
Timothy Cabral, '. .;a')
O
President
CSL-105454 ZM
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r-
M
58 I)ICKINSON STREET I FALL RIVER,MA 0272, I (r -4240 I � TIVEW�THERI7.ATION@G"L.COM
Z.
1 I
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f
�oT27
0 0
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7. �S Y
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THIS PLAN IS NEITHER INTENDED ' "Z�. NZAL MSUE s
FOR, NOR SHALL IT BE USED FOR NO. DAIE Ofscitr70N BYAS-BUILT FOUNDATION PLAN-LOT
MORTGAGE LOAN PURPOSES. Lcr 28 vE
°." 3.a eNS'T 4BLE MA SS,
I CERTIFY THAT THE FOUNDATION 4 SCAM- � '40 do® Na /398
SHOWN ON THIS PLAN IS LOCATED
PEE LEVY N�a l 0 6110
ON THE GR S INDIC No. 1CSY7
�o—Z 7-8fJ Ir��'S T i R,��/ EDT, Emu & Tian 148 mils K
DATE RE I RED LAND SURVEYOR Sr1c;�ij� ts�ot�to�
no ym ium erxar CWTIRMIX MA 02M �
/-,JF BARNSTABLE, MASSACHUSETTS
oUILDING PERM11
0 0 5.01.2 Augu*c
DATE PERMIT NO. "P
ZPL I'CANT "'ne r ADDRESS
0 0eft 13 9.
(NO.) (STREET) (CON TR'S L I CENSE 1
RMIT L -I
TO bu4id _'111�j',-Le I NUMBER OF
(TYPE OF IMPROVEMENT) NO. STORY (PROPOSED USE) DWELLING UNITS
t 41
AT (LOCATION) I
n y a ZONING
DISTRICT—
(STREET)
ICT_(NO.) (STREET)
BETWEEN
AND
(CROSS STREET)
(CROSS STREET)
SUBDIVISION LOT
LOT
BLOCK S IZE
BUILDING IS TO BE FT. WIDE BY FT. LONG BY
FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCT101
TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION
(TYPE)
REMARKS:
AREA OR
VOLUME 45,00o PERMIT 61.5G,
(CUBIC/SOUARE FEET) ESTIMATED COST FEE
OWNER V
0—. 5o E n DEPT.ADDRESS BUILDING
BY
FROM THE_b�PAAFY ENT OF PUBLIC WORKS THE TSSUANCE OF THIS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. PERMIT DOES NOT RELEASE THE APPLICANT FR&'THE CONDITION
MINIMUM OF THREE CALL
INSPECTIONS REQUIRED FOR APPROVED PLANS MUST BE RETAINED ON JOB AND THIS WHERE APPLICABLE SEPARATE
ALL CONSTRUCTION WORK: CARD KEPT POSTED UNTIL FINAL INSPECTION. HAS BEEN PERMITS ARE REQUIRED FOR
I. FOUNDATIONS OR FOOTINGS. MADE. WHERE A CERTIFICATE ELECTRICAL, PLUMBING AND
OF OCCUPANCY IS RE- MECHANICAL INSTALLATIONS.
2. PRIOR TO COVERING STRUCTURAL QUIRED,SUCH BUILDING SHALLNOTBE
M EMBERS(REAOY TO LATH). OCCUPIED UNTIL
3. FINAL INSPECTION BEFORE FINAL INSPECTION HAS BEEN MADE.
OCCUPANCY.
POST THIS CARD SO IT IS VISIALE FROM STREET
BUILDING INSPECTION APPROVALS
PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS
mow "- y ' ��
2
2 2
0
111L�lze.
L j:3_5 HEATING INSPECTION ION APPROVALS ENGINEERING DEPARTMENT
A kLl,�i
OTHER
BOARD Or HEAI_I I I
WORK SHALL NOT PROCEED UNTIL THE INSPEC- F PERMIT l.'LL BECOME NULL AND VOID IF CONSTRUCTION TOR HAS APPROVED THE VARIOUUS STAGES OF WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE ARRANGED FOR BY TELEPHONE OR WRITTEf-
INSPECTIONS INDICATED ON THIS CARD CAN BE
CONSTRUCTION. PERMIT ;S ISSUED AS NOTED ABOVE. NO11FICATION.
BUILDING PERMIT NO 3 3 DAT 0
ASSESSORS PARCEL NO.
CONTINUATION OF ROAD BOND
The undersigned owner/contractor hereby agree to maintain their road bond in
force unt'_1 the following work items are completed to the satisfact on or the
Engineering Section of the Department of Public works:
L/loan and seed shoulders as soon as
weather pe^its:
other (explain)
LOCnTIO::: / k1L1<02C
S1G:;ED (G:TNE3/(t7O.; CTO ) (print name )
;GIivEE=l ;G ACTHORIZATI'ON
I.
�F THE TOWN OF BARNSTABLE 3�116
� Permit No. ................
BUILDING DEPARTMENT
{ D8"x TOWN OFFICE BUILDING Cash
�a9�
�EEr�r HYANNIS,MASS.02601 Bond ...........�� /01
CERTIFICATE OF USE AND OCCUPANCY
Issued to Greenbrier Corp:
Address Lot #28, 41 Kilkore Drive
Hyannis, Massachusetts
USE GROUP FIRE GRADING OCCUPANCY LOAD
THIS PERMIT WILL NOT BE VALID, AND THE BUILDING SHALL NOT BE OCCUPIED UNTIL
SIGNED BY-THE BUILDING INSPECTOR UPON SATISFACTORY COMPLIANCE WITH TOWN
REQUIREMENTS AND IN ACCORDANCE WITH SECTION 119.0 OF THE MASSACHUSETTS STATE
BUILDING CODE.
�� ,%��
January..?9�...... 19...90......:.. . �!/:...rGr..... ..........................
Building Inspector
Assessor's offioe (1st floor): -'�.+ "' - OF7HE /�/
. .......4�— TO
Assessor's map and lot number ........................ `"� ..� ��♦
Board of Health (3rd floor):
Sewage Permit number " �..
Engineering Department (3rd floor): oo %639•
House number :..............................:............................... ' e rar a�
APPLICATIONS PROCESSED 8:30-9:30 A.M, and 1:00-2:00 P.M. only
TOWN OF BARNSTABLE
BUILDING INSPECTOR
APPLICATION FOR PERMIT TO .... :5? . ...
TYPE OF CONSTRUCTION ....... 5 ^{G�c r........ �?'`"':�, ........r,r:e oa ltt ""le
' ................................
......... �...................
................e ..............................19_
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit according to the following information:
Location �•0;> �?� .. f /El�nyn�t.J......................................................................... .
../...... .�. ....
r
Proposed Use CF '`'' �/�
................................... . ...........................................................................
Zoning District ... ./................................................Fire District .............................................
Name of Owner .... .: �Lc t./✓�S�l 0 . s 7 �� ..(.{ .i.vT�Xvli. ....................
.............................................Address ............. ............s.....
Nameof Builder .........S�� (� t�...I....................................................Address .................................................................................... x
Nameof Architect ..................................................................Address ...........'......................................................................
Number of Rooms ..................................................................Foundation ...r' ....4" (°olric'.. .r (F
Exterior ?L'C /?�5�( .....5 !'( t S 'C 4`1)"o a
Roofing ...........A.?:/��? .<.: ........................................
('/7 t f �V 1_.. . ..�......................................Interior ..........��ir 1 z'Y D C�
Floors .1........... ..: .... ' ...............................................................
Heating 1c° A ..:......G/�.................................Plumbing ' / j'r' rr�
r............... .... .' ..........................................................
° f ` UIFd
Fireplace ' ?.................................................................Approximate'Cost ....v...;..........G..............................................
..............
Definitive Plan Approved by Planning Board ____"__(__------_/__ "_____"___19 A_�: Area ..........................................
Diagram of Lot andi Building with Dimensions Fee .............................................
SUBJECT TO APPROVAL OF BOARD OF HEALTH
�7 1(f7
OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS
I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above
construction.
Name ...............................
"
Construction Supervisor's ;License ..D.. ..71
GREENBRIER CORP. A=272-005. 012
d
No 33116 Permit for ..1z...$t;.Qr.Y.............
........S i ng 1 e...F ami ly....VW
e.j l zUq.......
Location .Lot...UB.......4.1...Kil kQr.e...Dxiue
........................... ..................................
Owner ...Greenbr. e?� CQp,,,,,,,,,,,,,,,.,.,,.,,
Type of Construction ...Zraxae..........................
...............................................................................
Plot ............................ Lot ..............:.................
Permit Granted .........August 3, 19 89
Date of Inspection ....................................19
Date Completed ......................................19