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0029 LEWIS BAY ROAD
icy t Application number..K4.....SQ-11....... Fee........S215...vl6:......................................... s NOV 2 8 2010 � KAM Building Inspectors Initials.. . . ................. Date Issued.......... ...... " ........... . . ..... a9 Map/Parcel. 2:1 ............................................ TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDO W S/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project:' //NUMBER S ET VItLAGE n Owner's Name: 6l` �^n` l� Phone Number f O# 3 w6 e"f Y Email Address: b;4f 1� Q. 00 Cell Phone Number s Project cost$ Check one Residential y Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize 'j-0 ki to make application for g ennit ' ce with 780 CMR Owner Signature: Date: �i ��r TYPE OF WORK t Siding�F .0 Windows(no header change)# 0 Insulation/Weatherization 0 Doors(no header change)# Commercial Doors require an inspector's review EEJ�Roof(not applying more than 1 layer of shingles) Construction Debris will be going to CONTRACTOR'S INFORMATION Contractor's name Home Improvement Contractors Registration(if applicable)# (attach copy) N Construction Supervisor's License# (attach copy) Email of Contractor Phone number ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. .f APPLICATION NUMBER......................................................... *For Tents Only* Date Tent(s)will be erected Removed on number of tents total 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-4.30pm. 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: GV y t*n Telephone Number "50l�` l 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,s cific inspections and documentation required by 780 CMR and th n a 1 Signature IN Date APPLICANT'S SIGNATURE Signature `G % C�'/' Date A All permit applications are subject to a building official's approval prior to issuances 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): Address: City/State/Zip: Phone#: Are you an employer?Check the appropriate bog: 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 listed on the attached sheet. 7. ❑Remodeling 2.El am a sole proprietor or partner- . P P ship and have no employees These sub-contractors have g, []Demolition working for me in an capacity. employees and have workers' v' g Y 9. Buildingaddition [No workers'comp.insurance comp.insurance.# required.] 5. We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself [No workers'comp. right of exemption per MGL 12.❑Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑Other comp.insurance required.] *Any applicant that checks box 01 must also fill out the section below showing their workers'compensation policy information, t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees, If the sub-contractors have employees,they must provide their workers'comp,policy number. , I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy 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 under the pains and penalties of perjury that the information provided above is true and correct Signature: Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Perinit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." , An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to 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 certificates)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 Deparhment of T-A--+.,:..i..a ct,nn.ia vnu—bave..anv.ouestions regarding the law.or if you are regmred.to obtain a workers compensation policy,please-callthe.Deparhment-at the number listed below. Self-insiued companies shouia enter their self-insurance license nuniber 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 lice 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 Com mnwealth ofMassaahusetts IIepatttnent of Industrial Ac6dents office of Znvestigatioas 600 Washington Street Roston,MA 02111 Tel,##617-727-4900 ext 406 or 1-977-MASSAFE Fax#6.17-727-7749 Revised 4-24-07 w mass,gov/dla 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 cz:Name(Business/Organization/Individual): Address: 9a City/state/ :- 1111 // -jMO/ Phone#: UC/ Are you an employer?Pheck.the appropriate boyType of project(required): 1.❑ I am a employer with 4• 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 me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp. insurance comp.insurance.$ required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their, 11.❑Pl bing repairs or additions myself. o workers' comp. right of exemption per MGL Y � P � 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: x Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). . Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce u der pains and pe Itie erju hat the.information provided above is true and correct Si ature:�/' `Jl.'' "� Date: i p�4J one#:- 3400, / p 5 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: - i Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in.a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association..or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an`employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-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 burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. - The Department's address,telephone and fax number: The Commonwealth.of Massachusetts Department.of Industrial.Accidents office of Investigations 600 Washington.Street Boston,MA 0211.1 Tel. #617-727-4900 ext 406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 4-24-07 www.mass.gov/dia ,d►c CERTIFICATE OF LIABILITY INSURANCE I DATE(MM/DD/YYYY) ( 11/28/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Diane La Fleche The Dowd Agencies, LLC PHONE FAX 14 Bobala Road AIC No EXt:413-437-1062 vc No):413-437-1462 Holyoke MA 01040 ADDRESS: dlafleche@dowd.com PRODUCER CUSTOMER ID#: JOHNMCD-01 INSURER(S)AFFORDING COVERAGE NAIC# INSURED INSURER A:Utica First Insurance Company 15326 John McDonough Dba Mac Industries 30 Pleasant Street INSURER B Easthampton MA 01027 INSURER C: INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 100631841 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR POLICY NUMBER MM/DDIYYYY MMIDD/YYYY A GENERAL LIABILITY ART511591200 6/11/2018 6/11/20191 EACH OCCURRENCE $1,000,000 X DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $50,000 CLAIMS-MADE a OCCUR MED EXP(Any one person) $5,000 PERSONAL R ADV INJURY $1,000,000 GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2,000,000 X POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE $ HIRED AUTOS (Per accident) NON-OWNED AUTOS - $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB HCLAIMS-MADE AGGREGATE $ DEDUCTIBLE - $ RETENTION $ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N RY LIMIT ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? F-1 N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Workers'Compensation Certificate of Insurance to follow separately from the carrier. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Bill Taylor 29 Lewin Bay Road AUTHORIZED REPRESENTATIVE Hyannis MA 02601 ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD Cx 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): John McDonough D.B.A. MaC Industries Address: 30 Pleasant St. City/State/Zip: Easthampton/MA/01027 Phone #: 413-285-5805 kre you an employer? Check the appropriate box: Type of project(required): I am a employer with 4 4. 1 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 8. Demolition working for me in any capacity. employees and have workers' 9. Building addition [No workers' comp. insurance comp. insurance.1 required.] 5. We are a corporation and its 10. Electrical repairs or additions 3. 1 am a homeowner doing all work officers have exercised their. 11. Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL Roof repairs insurance required.] t c. 152, §1(4),and we have no 113. Other 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. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors 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: Utica First Policy#or Self-ins. Lic.#:ART511591200 Expiration Date: 6/11/2019 Job Site Address: 29 Lewis Bay Rd. City/State/Zip: Hyannis Ma. 02601 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, nder the pains and pe alties of perjury that the information provided above is true and correct. Si ature: Date: 11/28/2018 Phone#: 3-285-5805 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#: � 4, Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152, §25C(7) states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary, supply sub-contractor(s)name(s), addresg(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 pennit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Revised 4-24-07 Fax# 617-727-7749 www.mass.gov/dia ESTIMATE #EST-06 0003 lac In ttiltr ie MaC Industries 30 Pleasant St. Easthampton,Massachusetts_0A077r USA EsfinTate Date: 27 Nov 201,& Butt To Br"II.Taylar, E�€�rr3�Date= 28 Nov 20T8. } Remove e sting Shingles.roof underfayment,drip Edge,ice and 1.00 5,300.00 5,300.00 water,lashing and plumbing boots and install architectural shingles along with all nevv materials in place of demo as vvell as a idp cap mstalladon, Sub Total 5,300.00 Total $5,300.00 AK9/ne Ott doteshlel ���`r�,�f".a �cs •-� �'' � � � g /: W'eapRrreciatey,owr,Rswsi.ressared'rce�aat�y,Qar,IPapRrcecia.aeaWu'est�R� l ?��e,rg, *r"' Terms:&Condi6oas U part,eccetasan e liar pGcmpose knategiat arad labor iru.ies W stateo jseb,an"snitez l d-epositof Reis required and remainder upon E0u'�.pletiao-t,. ACC)PRLIP CERTIFICATE OF LIABILITY INSURANCE °ATE'MMID°"Y"Y) U F11I28/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS 'CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE.OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Diane LaFleche THE DOWD AGENCIES LLC PHONE Et)o (413)538-7444 FAX No: E-MAIL ADDRESS: dlafleChe@dowd.com 14 BObala Road INSURERS AFFORDING COVERAGE NAIC# HOLYOKE MA 01041 INSURERA: AMGUARD INSURANCE CO - 42390 INSURED - INSURER B: MCDONOUGH JOHN INSURERC: TA MAC INDUSTRIES INSURERD: 30 PLEASANT STREET INSURER E: EASTHAMPTON MA 01027 INSURER F: COVERAGES CERTIFICATE NUMBER: 341879 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. ILTR TYPE OF INSURANCE _Jb5a ADDLSUER POLICY NUMBERMM%DDY� MMLICY EXP /DD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE OCCUR DAMAGE T RENTED PREMISES Ea occurrence $ MED EXP(Any one person) $ N/A PERSONAL&AOV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY PRO- LOC PRODUCTS-COMP/OP AGG $ JECTI OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT .: $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS N/A BODILY INJURY(Per accident) :$ NON-OWNED PROPERTY DAMAGE $ HIREDAUTOS AUTOS Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE N/A AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION /� SPR TATUTE �RH AND EMPLOYERS'LIABILITY - ` ANYPROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $ 100,000 A OFFICER/MEMBEREXCLUDED7 NIA NIA NIA -R2WC916050 - 06/12/2018 06/12/2019 - (Mandatory In NH) . E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under _-- DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If more space is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/` Sole proprietor has not elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,, NOTICE WILL BE DELIVERED IN BIII Taylor ACCORDANCE WITH THE POLICY PROVISIONS. 29 Lewis Bay Road AUTHORIZED REPRESENTATIVE Hyannis MA 02601. Daniel M.Cro v y,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD CAPTE""EdV'T"" N S UITWifl-0 N;a 8: 56 Ed Iq N® FI8ER GLASS SEAMtRSSee1DP.R.4_ SYENDED RARS 1-800 -� 6��11 o/c 6--7-13 Town of Barnstable Regulatory Services Building Division. 200 Main St Hyannis,,MA 02601 Date: K(f a1 3 Dear Building Inspector Please accept this Affidavit as documentation that Cape Cod Insulation, Inc. performed & completed the insulation and weatherization work at the property listed below. Cape Cod Insulation did this in accordance to the specifications listed on the building permit application. All work has been inspected by a certified Building Performance Institute (BPI) inspector. All work preformed meets or exceeds Federal & State Requirements. Property Owner Property Address Village Insulation Installed: Fiberglass Cellulose R-Value Restricted Unrestricted Ceilings Slopes kie'e )0 ) ( ) (X ) Floors Vi fe ( ) ( ) ( ) ( ) ( ) //W alls ( ) (�O (37 ) 4 - Sincerely hECasJr, President on, Inc. 1 i t. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION ` Map . Parcel Application #0?01 66 Y 7 I • Health Division Date Issued Off. Conservation Division Application Fee Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic.- OKH _ Preservation / Hyannis Project Street 1dress Village Owner Address 7� Telephone J AP- Permit Request &Or r111 /,Off &A�� i e6ffa Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation �� Construction Type Lot Size / Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family CY Two Family , ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including bath,): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other v � o Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood al stove❑Y! ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: +sting 341ew size_ _ w . Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal #~ Recorded ❑ 'a a Ln m Commercial ❑Yes ❑ Ne/ If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name ( Iw Telephone Number a p Address �() - G�"� License # �� D ' (kkoul'y'4'. �Vv V Home Improvement Contractor# Worker's Compensation # �� ✓ ZS��/ ALL CONSTRUCTION DEBRIS RESULTI G FROM THIS PROJ CT WILL BE TAKEN TO SIGNATURE - DATE �� '[[[; FOR OFFICIAL USE ONLY 't 'g APPLICATION# s DATE ISSUED s j MAP/PARCEL NO. iy ADDRESS VILLAGE >= OWNER �y t DATE OF INSPECTION: r FOUNDATION FRAME INSULATION FIREPLACE 4 ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL } GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT t ASSOCIATION PLAN NO. U r r rr0�'P?2' ofEain-EtZE . eglxlato y �`e IC " Bailcling Diymon '`rho►,tk` ,. ' mo=as Pzrrpr CB Or'Badding Camm.ilszaxiei- 2DD 2 ain.Sfiu� $yLcds,MA D•260I t 'x'�r.tQwn.bar�sfa6l�maars .. - D$�acc 50g-862-¢038 f-ax:.5OB-79M73D' PLAN REM Prat ectAddress�� `5 Builder-• �V'e C ��5�la �ot/J The faIlaw?tig jtee as w� noted:on reviewzrig: ��St. i�G �2� a • Ca! •G' ova Qi� • ' • . RaYiewed by: ; t%` Dad S i -.-... . }' IMaNsachuscus - Department of Public Sareh Boar(1 of Builtling Rowlations and Standards. Qonstruction Supervisor License a b' Licen CS 100988 HENRYIN CASSIDY 8 SHED ROW WE:itT '*ARMOUTH, MA 02673 Expiration: 11/11/2013 ('uuunissiuner Tr#: 7620 _- Office of Consumer Affairs and Business Regulation 10 Park Plaza -'Suite 5170 s Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 153567 Type: Private Corporation Expiration: 12/15/?_`b14 Tr# 233831 CAPE COD INSULATION, INC HENRY CASSIDY 18 REARDON CIRCLE. -- ------. — - — -- SO. YARMOUTH, MA 02664 Update Address and return card. Mark reason for change. Address 0 Renewal rJ Employment I_.._I Lost Card SCA 1 t) 20M-05/11 - '/��( l('f'JII YILO�LCLK,CF(r"fG P1/0l,,JJock,I Je Office of Consumer Affairs& Business Regulation License or registration valid for individul use only before the expiration date..If found return to: OME IMPROVEMENT CONTRACTOR p egistration: 1'S3567 Type: Office of Consumer Affairs and Business Regulation f xpiration 12/1`5/2014 Private Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 CAPE COD INSULAT'ION;';INC:, HENRY CASSIDY 18 REARDON CIRCLE � _ o S0.YARMOUTH,MA 02664 ' Undersecretary Aorwitho t nat re Prtnt Form,, The Commonwealth of Massachusetts a Department of Industrial Accidents. Office of Investigations I Congress Street, Suite 100 r Boston, MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/individual): fah lah dml Address: &VAk �vd,& City/State/Zip: I/!NG `�- MA' Phone #: r2O�- Are you an employer? Check t e appropriate box: Type of project(required): 1. 1 am a employer with M 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub-contractors 2.❑ 1 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 me in any capacity. employees and have workers' [No workers' comp. insurance comp. insurance. 9. ❑ Building addition required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions myself. o workers' com right of exemption per MGL y t p c: 152 1(4), and we have no 12.❑ Roof re a'rs insurance required.] , § �e������D employees. [No workers' 13.� Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: do-Fly Policy#or Self-ins. Lic. #: WGA ODzj �� DI Expiration Date: Job Site Address: V 1 City/State/Zip: � �G1 r`:'`r Attach a copy of the workers' compensation policy declaration page(showing the policy number Ind 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of - Investigations of the DIA for insurance coverage verification. I do hereby cer " n-ler the ains d enalties o er ug that the in ormation provided above is true and correct. Si nature: Datel V 1,7, Phone#: 1 Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority (circle one): l.,Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector* ' 6.•Other Contact Person: Phone#: I No, CUe,1W 45a7� � C;CIN�UL AG -- CERTIFICATE OF LIABILITY II�IISUI���NCE UAICIMhIrI1lI,YYYYI 7N18 CEk'rIFICATL-:IS ISSUkO qS A MATTER QF INFORMAIJON ONLY ANI)CONFERS R07 NQ lGt1T8 UPON 711E CERTIFICATE HOLDC'it�711121 aS, CERTIFICATE DOES NUT AFFIRMATIVLLY OR NEGATIVELY AIVi AD,EXTEND OR ALTER'l-FIE COVCIiAGL'AFF'Or EI) UY TI-IL POLICIES k1k:t LJVV 11-05 CERTIFIGATL QF INSURANCE DOES NOT CONSI I I H IE A GUNTRACT BETWEEN THE 1,;) IINC;INL+UI1Gtl{(S),AU I WRIL.LD REPRCSL:NTAI'IVE 01-t F'FIODUCFR ANN T-HF CERTIFICATE IIULirCR. If4'PpI1TANT If tho carH1`1 rtu huI tal iv al,AbOITIONAL IN`aUhft 11 Hh) pgliCy(ies)mU,16e enclur�ecl.II SULTIi(1GATIC)N I.;WAIVED, ---- ro nc �nms anal wltglllunx of the pullcy, call yln policles may,„l'u',un arl clgraamartt.'A ala Lament qtl(hlti Lt3l Hrlt Ula(1Ut;l'IIuI 4'4111Cf 11U1,k:(U(IIG L 4,lINl.�lu holdL r u, lu (r r;,{'tiU4t1 tlll ClUr;14111C111(�), Rogcr s &Cir ay 141-3. -So. C)nrtru>a wkhrE IMVI ti let YUL)"Ll T dJd huuty I J4 PHONE 508 760�tGO� l !�-FAX )NC No EMI J&C N, 11// ll l ti•1 W E h1AIL --- _. �. SUtf:f`.lU-l;lill) - .�— muushnittlAr=r(alrt!mu�ovt-tvAaL tNwLIRENN; eUf1@$S Insllrallcu ------ I U3.13 1NSURER8-fVi1iIAWfi Insurartcu C 01k1patrly .. "• ___._ Cape Coe! Insulrltfti�n tnc __. 1`,5 Y:,nmouth F:uaU INSUheac:Atlzlnlic Charter Insuranet,. Ilyluulit�, MA 026U7 MURNIvq Canutlerce Insurance Cunt jn d/ c LltflF 1C.A'I k NUMt1ER REVISION NNIVH.-J fi Itu; ti fO CFl�lt!'1 111AI llli. IuOt IL.IL.:S ur wtiL:pANCE uslpn n�; tM1 HAVE BEENISS(lEU TOME MU RGD NAMEDADOVE 1=0}t 1FIL Pt)Ltti_1.P6i;loo n-. I t.L. Nu lvdl l r l;a t ANUINia PINY Rt;laulr kMIk.NT,1 ARM OF l OiJI;II lOI'I OF AIVY CQIITRACT OR OTHER DOCUMENT WITH RESPt:CI 'fO WI lic l IIil, .l:Kll(It.Alli MAf ESt hSilll:iD UR MAl` PE,R'iAIN. 1'HE INSURANi:L-.1r(r171fDEQ BY THE POLICIES D2SCRIDED HEREIN IS SUOJE.CT fO ALI 'flit'. '1'1:1Q6, 'rC(.11,l(IN7 AIVD CQND1110N5 pF SUCH PQLICtEy'. LIMn'S SHGwN hl��Y rh qWE DEEN RCDVCED BY PAID CLAIMS. rfR I Yrh,of INyURAWG6 -.. AQUL SUQ47 -- - _ POLICY EFF PitLIGY tick '"�'•" -� -�-�- ----•---�- _._..:_�., IMMfOpMYYY�(MM1gt1/Y1'YYj _ L.INIfrB/.'l lilNLkAI.I IAkr IL.IT I' —'— - - C BP82630&3 410112012 0410'11201' tAcrloc(HHrtrNr r: y;1 ODU Ul1U C7Mhtl-N(,L4.L GL NEHAL LIABIL11Y --`---+--- p `11g1�L�, t kNtL,n y.'IUIII)UU . ..I CLAIMti-AM1AUE. _}_[ OCCUR « 3 .. f��7•ilh1,.1N'�__T,_�I__ .._._�,..___._.:� " - tl Exl'(Ally unwQd(Harl).__. 5 0 01�RBQPIAh a AUV IN)unY I UQU UUU _ $2.000UUU . 1-11l Al, Hll1A) L.IM11/PNLIL;jI NI R: _... __ F'GfiJ- PrtUUUC;TN GOMI'Ifar AL l— yi 1()Ul)goo. r i) nunmtuk,ll.kuxt�lul'Y _ T� � CUhIIjINLDEINGLCl1611T r 12MMEtCKVmii; 4112012 04JU•It2>01, �3 dL,INt D I QUO QUu ['11 e I. All t10pILY INJUM' uwNr.0 ticl(L'ImiED n �__.. AU I OS BOUILV INJURY(f o:, y n4). t,, x wi(LU Au x - — NUN-UWNkL) I _ AU rG i NRQPGfi11`QAHIAC1f; -- - -- -_ _ H X uMtlnk LLA LIAC til.t.ur� )CONJAS351.! 41010OU 04/01121)'1'' E.4CiIgL:CUIthLNI.E .11 OOO QOU f l L ilAlu NIAQC - - AGGr<kGAI'k J•1 LUUULU(IU Ll X C Lvu,rncNplVlYiMkNt/AIIQN AND kMI+LOYER.,4 1 1AOILIIY - _ VVGA00525O(h' 6W120,12 06)3 )2011+ ANYI lln„lalc'(�1 r,v' c tt J� n))rrII r33r}-eaui IVR YIN C L.coca l ACGInr N 1 1 UUU U00 IIFfIC k}I/rolhlrlBk}t LkCI.U()L:L1h �N� N)A -_ - it x . Id nuo,In to L.L.plscASL I t CMPI rn Lk t''I UUU UUU y -------•--•--._..___.._.___-.._.._ -,.' �uCS,-hilPilON OF Jrl I�A11QNti lioluw ' G.L p15LASG Pp(Ita'Lll.lif y'I ODU 0OU Ur7i;t111'I!UN l?I'OVtkAI IQNS 7 LOCAT IONS-I VLMCL ES(AL1.0,ACORI)tU 1,Aadhl:,,,i ie,„a,t�dghyuWtl,It I�VIV VNNCtl 16 Itl1111I1tlQ) Warliers Comp Infottnatluri ` .4 Illy,uu(I()rylcefo,Q1' P1ropriator5 -- (altlrlcace hlcil ac r i 1r1QIudGd mi rtn dUclitional insuft)d ullclur( uncual LiUOility wtlon roqulrod by wrltten cun(rrlct or agreement.17 , '� ei21'IEICA)t 1{0[ULFt �_..:. , .__ •_:---- _:.__._ CANCELLATION „ [:upU GLIO II1liUla11Q11,ICIC 3HOULD ANY QF THE AbOVC QE. CI HWOP0L.IC.Ikti13EGANGIt'111,)WOOkh THE EXPIRATION DATE THEREOF, NOTICE WILL HE .L)kLIVL-kkti M ACCORDANCE WITH THE POLICY PROVI310Nu. '. AWN-10HULU REPR@SEN I ATIVB ( iF)U 2010 ACOIiD CORPOFIA110N,All rl0hlt rvm m(. (.U1 U/US) .1 (1t-'I' The AC ORL)II,1una 111d logo lrru cuUlsterUd marks of ACORD . MI~Y OWNER AUTHORIZATION FORM (Owner's Name) . owner of the property located at (Property ddress) NiS �--a- a (Property Address) hereby authorize Jarr& U Ii (S con or) an authorized subcontractor for RISE Engineering,to act on my behalf to obtain a building, permit and to perform work on my property. i ��� p.� . ter•^ ,. .. • Owner's Signature Date TOWN OF BARNSTABLE SIGN PERMIT PARCEL ID 327 227 GEOBASE ID 24329 ADDRESS 29 LEWIS BAY ROAD PHONE HYANNIS ZIP - LOT BLOCK LOT SIZE DBA DEVELOPMENT DISTRICT HY PERMIT 81681 DESCRIPTION 12 SQ HARBORSIDE CHIROPRACTIC PERMIT TYPE BSIGN TITLE SIGN PERMIT CONTRACTORS: Department of ARCHITECTS: Regulatory Services TOTAL FEES: $25.00 BOND $.00 drtNf CONSTRUCTION COSTS $.00 753 MISC. NOT CODED ELSEWHERE 1 PRIVATE OsnRvsTAsr.E, MASS. 1639. BUILDI D%VISION BY DATE ISSUED 01/11/2005 EXPIRATION DATE " �"` Town of Barnstable FZHE loy, Regulatory Services "o Thomas F.Geiler,Director} ■ \ 11 " '" MAS& Building Division 13 VU(( �Aipp �a Tom Perry, Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us__.,_..4...._ - -- ,, ,3i� E Office: 508-862-4038 Fax: 508-790-6230 Tax Collector Treasurer Application for Sign Permit Applicant: ` �'` / �'` Assessors No. Doing Business As: �/!�/Zt�86 �E C11ROAUC-riC Telephone No. ��� 775=IP3�- Sign Location q L �s (-3 Street/Road: ; / 1 Zoning District: Old Kings Highway? Yes Hyannis Historic District? Yes[ Property Owner Name: !�i/l�f l Ga`\ Telephone 'PT 15-j U /� Address: � �f/�l /�� �'`�C Village: ' Sign Contractor,/ _re� E� _ Name: "/he, S jW Telephone: Address: "74 1�KJT OA) Village: Description Please draw a diagram of lot showing location of buildings and existing signs with dimensions,location and size of the new sign. This should be drawn on the reverse side of this application. Is the sign to be electrified? . Yee (Note:If yes, a wiring permit is required) Width of building face ft.x 10= x.10= _ I hereby certify.that I am the owner or that I have the authority of the owner to make this application,that the information is correct and that the use and construction shall conform to the provisions of Section 4-3 of the Town of Barnstable Zoning Ordinance. Signature of Owner/ uthorized Agen G Date: .Size: � , Permit Fee: Sign Permit was approved: ,l' �.w S Disapproved: Signature of Building Official: �(�-� Date: /� O Q I WPHLESI SI GNSI SIGNAPP.DO C t a r �v dlS 0 D Magnook and Treatment of spDirt o and spm� W,ugReo Da Wffiamm Ho Tzy�w9 DC, CC SIP o 4Cgyl�, ly ,r r}�ick MDa PLywoa� -73" po.Sfis i Ir Diagnosis and Treatment of Sports and Spinal Injuries 775 - 1935 Dr. William H. Taylor, DC, CCSP B o HARBORS DE Diagnostic and Treatment of Sports and Spinal Injuries � 775 .,, 1935 Dr. William H. Taylor, DC, CCSP ME -M�,t W. "1tOv ) '} �O.Ymshi•II��S�`` v i�. �i�,�r 4rq � /,,'�•"�",�'t'�'.F?+5i ,��u`a��3+a��'y i s F R3 5, �s�'Ss,�i � r L5 @r� °�'�•5'. Q . Y•e@gym 'd.+ 1'.R. r w t•y r `-� ]3jt�' � .fta,(f ! �a aPl m9i. ii5 �gg I W w�, ail.-. IMF .� 11 "& a - ¢� ,:?»k ,.�,, .-,•ws." ., fit•s. .� zwt 'fA _ ri p67� � ii�i �l ffia II _ r l # '� fi:.. SS` F 5o�n-' i assrf► �--=- r �d aE • � • Sl a r t jA�}4��is g I •`Y "1`IJy(��. �' � � �_w �L1YI l.d.1.L.1��l.. d'��S,�p� ,�' ,�,,C� � � fie•\�rth'�'��+� /ft On" OWN"_ mop"--M .. C R.^R _ y J S A 1r Orrt� p r .......... MAI P ME ! v€ j • �� � __m - � ,7 ��� alb � l }, r s Apt .:•ra '� u— �sYi� i ay,•' �+"�� ti' `� +, vf�' 'ay"'q# � �,•`a� �i�.f' ' �•+"'f' .a'�,i, Y` a^;r�.�..r�•as'� .,t%'S.. '.l�i� �'s�v. *�...'�32ay V,n, Z}r3-.�'. �i�,e, ., :_.s.. TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map s 3 oC"= Parcel d a 7 Permit#' ' .� - - J Divi Health sion �l Date Issued �� Conservation Division be Application Feed©' Tax Collector Permit Fee ,• r Treasurer bit(0 r; APPLICANT MUST OBTAIN A SEWER Planning Dept. CONNECTION PERMIT FROM THE ' ENGINEERING DIVISION PRIOR TO Date Definitive Plan Approved by Planning Board CONSTRUCTION. Historic-OKH Preservation/Hyannis Project Street Address �- LaS ►�X Village Ho AIQ/U!S Owner C L-L1 f _-r;�� tok_ Address LkWtg 9.44 • Telephone (�C' � / �= ® 360 1?2'(� Permit Request ®� ��/�1 .° ®�� - �� �� 74 DOM\ Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District �n Flood Plain Groundwater Overlay Project Valuation Construction Construction Type Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family V/ Two Family Cl Multi-Family(#units) Age of Existing Structure 14V Yr5i Historic House: ❑Yes Qd No On Old King's Highway: ❑Yes *<O Basement Type: 3e Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing new ® Half:existing new Number of Bedrooms: existing new Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑G Oil • ❑ Electric ❑Other - Central Air: ❑Yes [�No Fireplaces: Existing Existing New Q wood/coal stove: Yes C'( o �— 9 Cl Detached garage:Cl existing ❑new size Pool: ❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing O new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial N Yes ❑No If yes,,site planreview#_ Current Use i<a- ~ ��• Proposed Use S__hV61f AXW7111I _r,,( e� . . BUILDER INFORMATION Name I� Telephone Number Address License# kLM O U T / A 0a �_V Home Improvement Contractor# ( e-7 Cs Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE FOR OFFICIAL USE ONLY PERMIT.'NO. DATE ISSUED _ MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION:�/ 6 7 iV'f✓-t FOUNDATION �/r FRAME o? 6`/F 7./A/,,•''a IV � INSULATION FIREPLACE - r ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH. r ' FINAL FINAL BUILDING -DATE CLOSED OUT ASSOCIATION PLAN NO. The Commonwealth of Massachusetts Department of Industrial Accidents xi , -- _ 660 Washington,Street s Boston,Mass. 02111 `s Workers'.Coin ensation.-Insurance Affidavit-General Businesses name: address:' ci wor site location full address ®! I am a sole proprietor and have no one Business e: 0 Retail❑Restauran ar/Eating Establishment working in any capacity. Office El Sales(including Real Estate,Autos etc.) ❑I am-an em to er with etn to ees full& art time)'. ElOther % � I am an employer provitiin_g vzorkers' compensation for my employees working on this job. com an •game, - '�r ad . 'xi ',ice•' — / goicX4. am a sole proprietor and have hired the independent contractors listed below who have the following workers' mpensation polices: com an name: address:. L.'.' glib De.. City , •:Z•.�: i•i.. o-: 'O�ll C :# irisrance'Co.: - - - - - / FM ::. q, { con an. narde: _ address: cifv _ aihone , Failure to secure coverage as required under Section 25A of MGL 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one years'imprisonment as well as civil penalties in the form of a STOP WORK ORDER and a fine of$100.00 a day against me. I understand that g copy of this statement may be forwarded to the Office of Investigations of the DlAfor coverage verification. I do hereby certi u er the p s and pen o e Wry that the information provided above is true and correct Si tore Date `® � Phone# Print name YEO official use only do not write in this area to be completed by city or town oMcial city or town: permit(license# []Building Department ❑Licensing Board C check if immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone#; ❑Other (revived Sept 2003) Information and Instructions Massachusetts General Laws chapter 152 section 25.requires all employers to provide workers' compensation for their. employees. As quoted from the f`law", 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 ajoint 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 erriploys.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 section 25 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,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. y Applicants Please fill in the workers' eorapensation affidavit completely,by checking the box that applies to your situation.. Please supply company name, address and phone numbers along with a certificate of insurance as all affidavits 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 Departrrient at the number listed below. . City or Towns . Please be sure that the affidavit is complete andprinted 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 b�e used as a reference number. The.affidavits maybe returned to FAX unless other arrangements have been made the Department by,mail or . The Office of Investigations would like to thank you in advance for you 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 Me of Imsngawns 600 Washington Street Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617) 727-4900 ext.406 N.. Town of Barnstable oF�x�r4y, ''�"�•� Regulatoky Services a�nxSTOzx,$ Thomas F.Gefler,Director 9�pl16 59. �•� Building Division TomPerry, Building Commissioner 200 Main Street, Hyannis,MA 02601 ' Office: 508-862-4038 Fax: 508 790-6230 Property Ownet MUSt Complete and Sign.This Section If Using A Builder Z _ .,,as.Ovwne�.ofthe.subjectptopetV hereby uthorize - - .to:act tin my..behalf,. a - is all inattets relative to work author z�cl•by.this building•pe=a--application fnr: (Aidtess of ob) Signature of Owaet Date PtiatNatiae r (,; t ..:. .rf+ircs�v. .seY-pv.a..:r a:: Y-.:t.s?!y.- ' •tv�a. ...:..',�:. _ ONE BOARD OF BUILpING RGULATIO,NS OR ' 1 License. CONSTRUCTION SU'PERbISOR B Numberr 034189 f 4 Bart 4t t a / 935 Xpi�e t01 2 R 6 Tr.no:' 16257 i14792 . 9 _. .• Res ,ie 0 la y ANTHONY R FARO _ i .,5 4 DEEPWOOD RD E FALMOUTH, MA 0 ' 'mow _ �Y. Acting o miss' ner C`FALMOUTH, MAIM Administra r Board of Building Regulations and Standards Licence or registration valid for individul us HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return t V Registration:`"1x07653 Board of Building Regulations and Standarc Expiration: g/52004 One Ashburton Place Rm 1301 Individual Boston, Ma. 02108 \NTHONY R. FARIA knthony Faria i Deepwood Dry - Falmouth, MA 02536 - ------- Admini;str.itor Not valid ithout signature r OFIIKE rp� Town of Barnstable Regulatory Services &UMSTABLE. ; Thomas F. Geiler, Director MASS. 39. Building Division i6 ���' ArFDN1°�p Tom Perry. Building Commissioner 200.Main Street, Hyannis, MA 02601 Office: 508-862-4038 Fax: 508-790- 6230 April 1, 2004 William Taylor Lewis Bay Road Hyannis, Ma 02601 , Re. SPR 008-04 Harborside Chiropractic, Lewis Bay Rd, Hyannis (R327-227) Proposal: Establish chiropractic office in existing residence Dear Mr. Taylor: Please be advised that your proposal was approved by the Building Commissioner on March 17, 2004. All construction and site work must be completed in accordance with the approved plan entitled Site Plan of Land prepared for William Taylor in Hyannis, Massachusetts with a revised date of 2/24/04. Upon completion of all work, a registered engineer or land surveyor shall submit a letter of . certification, made upon knowledge and belief in accordance with professional standards that all work has been done in substantial compliance with the approved site plan (ZO Section 4-7.8 [7]). This document shall be submitted prior to the issuance of the final certificate of occupancy. cerely, r Robin C. Giangregorio s Zoning & Site Plan Review Coordinator 06/09/2004 12:26 915087906230 PAGE 01 T Town of Barnstable,- O , , Regulat6ry Services k ! BARNSTABLE Tbomas P.Geiler,Director 2004 .SUN 22 AN 8: 53 Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 0260'r -�a : ww►v.town.barnstable.ma.us uI1510N Office: 508-862-403$ Olt,( Fix: 508.790-6230 PEItPVIMT# '7? (1 G G FEE: $ SHED REGISTRATION 120 square feet or less tion of shed(address)e Y age _ C - `zoperty owner's name elephvae number Size of Sled a` r Map/parcel# a�,tralz.:�_ ✓ Signahre � Date Hyannis Main Street Waterfront Historic District? NA Old King's Highway Historic District con,ruission jurisdiction? N� Conservation CoMission(signature is required) / PLEASE NOTE: IF YOU141THIN THE ON OF ANY OF THE COMMISSIONS,THERE ARE Y BE A REVS PROCESSIAND APPLICATION FEE. vi, PLEASE SEE THE APPROPRIATE COMMISSION FOR DETAILS. THIS FARM MUST BE ACCOMPANIED BY A PLOT PLAN Q.fbRns�shedrea JtEv:121901 L BWS&B,LLP OnCVn EM 1 wTNCPt SIMLN, BOLAN LLP gage a /a6/20i92 11:56 15285539235 WILSONASSOCIATES PAGE 04 DEED 80OK 2005 is LENS BAY ROAD PAGE 100 7o ± 32't r� 429 GARS.GE , ,�/ J 2 STY t1 DWELL C_ bo C^. N/F HENSON N/F NICKERSON S'r NOTE: LOT 701f Q PPD, CGNf1GUFiAl10N FROM ASSESSORS Mf�PS �"" ` MORTGAGE INSPECTION PLOT PLAN SCALE: I" = 40' 29 LEWIS ]BAY-ROAD DATE: NOVEM IER 5, 2002 HYANNIS, MASSACHUISE-M—s WPILLIAhd TAYLOR certify thot the structure is located on the lot as shown and its location DoeT conform to the Zoning requirements of the Town of BARNSTABLE of the time of construction. ! further certify that the structure is not located in the 100 Year Special Federal Flood Hazard Zone MAP 5C COMMUNITY PANEL 250001 DATE: AUGUST 19, 1985 ZONE C GENERAL NOTES: The declarations mode above ore on the basis of my knowl'zd9 e, info% the result of o site inspection made to the normal stondord Of arP t mOaOn and belief as s::rveyor. 2. This plan was not prepared for recording purposes, tor, use is preporeing deed de3cripiions or for construction purposes. 3. Verification of, property line dimensions, bul c ir,q Offsets, fences, or lot configuration may be accomplished only by on accurate curvcy. WIISON ASSOCIATES PREPARED FUR ENGINEERING & SURVEY, INC. 205 EAST CENTRAL STREET SHERWOOD VORTGACE GROUP F'RANKLIN, MASSACHUSETTS 020U • a4—76J N/F MICHAEL J. BEECHER � r� t � NIF WILLJAM ARCHIBALD ,t Handicap Ramp — Design By Others e C++ . °' , r 34 33 32• 31 ,45 2 ` 81.80 'F11TD 227. ExistlnB' LI, 4 y r- Existin n Pa Q. ;[ �' p -=ti 1 57sq.ft i Garage - 6' ved Dri ve tvay ps I CO ,Proposed., Cl) f�. 'i` }- Gra vel , p �: r Parking 1 W k�, 4 ode G'.IIW'ELLI,N I :. I � E�S�PROPOSED. q t �DP1y H `OFFICE US'E Existing Walk F V 44 34- 1 31 96. CEj' {h 5835213"'EY g.71U 95• - .. e / N83 53 , -- u/, t r edge of existin 33 320' "W O Y pa vemen t NSF, LE US BAY ROAD CO NDOMINIUM . 9, y��}�'(.��k��. a it 1'��7-v 'ham'•., . .. Locus Address: wj, Ra v Road �oF"E rpm Town of Barnstable Regulatory Services BAMSrABLE, : Thomas F. Geiler,Director 9� �•� Building Division Tom Perry. Building Commissioner 200 Main Street, Hyannis,MA 02601 Of€tee: 508--8-62-40H Fax: 508-790- 6230 April 1, 2004 William Taylor 29 Lewis Bay Road Hyannis,Ma 02601 Re: SPR 008-04 Harborside Chiropractic,29 Lewis Bay Rd, Hyannis (R327-227) Proposal: Establish chiropractic office in existing residence Dear Mr. Taylor: I Please be advised that your proposal was approved by the Building Commissioner on March 17, 2004. All construction and site work must-be completed in accordance with the approved plan entitled Site Plan of Land prepared for William Taylor in Hyannis, Massachusetts with a revised date of 2/24/04. Upon completion of all work, a registered engineer or land surveyor shall submit a letter of certification, made upon knowledge and belief in accordance with professional standards that all work has been done in substantial compliance with the approved site plan(ZO Section 4-7.8 [7]). This document shall be submitted prior to the issuance of the final certificate of occupancy. Sincerely, Robin C. Giangregorio Zoning& Site Plan Review Coordinator TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION z ,� 6 Map 3�) Parcel -)-d Permit# 10 �F BARNSTASIE � Health Division Date Issued g f 4r Conservation Division T � 29 FM 4: OS Application Fee Tax Collector Permit Fee Treasurer 1171S-10 Planning Dept. s Date D e Ian Approved by Planning Board Historic 1 '�� P�setvatton/Hyannis Project Street AddressIq y Village l(LIMAJ fS Owner / CLi Addressazy L/&,,)rs LAI �• Telephone Permit Request , �� f e_ o&_1-_ P e.,,1%,4 VV Square feet: 1 st floor: existing 00 proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuatio Construction Type � ® Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. r Dwelling Type: Single Family ❑ Two Family O Multi-Family(#units) ' ' Age of Existing Structure Historic House: ❑Yes On Old King's Highway: ❑Yes G;) Basement Type: ❑Full ❑Crawl ❑Walkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full: existing, new Half:existing new Number of Bedrooms: existing new Total Room Count(not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air: ❑Yes B/No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ulo Detached garage:❑existing ❑new size Pool: ❑existing ❑new size Barn:❑existing ❑new size Attached garage:QYexisting ❑new size �he�®existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded O W/4 Commercial CIYes ❑No If yes,site plan review#r Current Use &SC-A AS A Proposed Use _R&M.VAC ��r�GM� C-fit►-�t4't• ; BUILDER INFORMATION Named l'��� % Telephone Number (lvAddress L PS ; License# /V ice ' 8 1 Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE Cr-�Z� f-� DATE FOR OFFICIAL USE ONLY PERMIT.NO. DATE ISSUED s. MAP/PARCEL NO. 1 r t ADDRESS VILLAGE t OWNER DATE OF INSPECTION: f FOUNDATION FRAME INSULATION ,D ;w FIREPLACE 1 ELECTRICAL: ROUGH FINAL S PLUMBING: ROUGH FINAL 1 y A GAS: ROUGH FINAL '�• FINAL BUILDING DATE CLOSED'OUT t; F , ASSOCIATION PLAN NO. The Comtiarinivealth of Massachusetts . Department of Industrial Accidents 6d0'Washington Street _ Boston,Mass. . 02111 V s•' Workers'..C m ensa&n.usuranceAffidavit-Gen eralBusfnes`ses MA Ant- TIP/ OIC er3dress: � T � S state: zi hone# _. work site oatioli fait []Retail[]RestaurantBai/EatingEstablishment [] I atn•a sole proprietor and have no one �a s'type; []office'[:) vror�ng in any capacity SaTtis(mclnding REal'Estate,Autos etc.)' I am an em 10 er with etn'lo'ees full&' art time . WoY th���/%%%/%///isu/�..�%%% %/%/////%%////%///%/%%% � es worlang on this fob.,z/�a�m an.iployer providing vprkers oOmvensation for my emp ' •r. t! .}' •i:rC.(O�T••i:l tit�,�C,,,4ri•:�t.,.••'.•:� ••'^'t��.r�:A{�ii• .;14:r`.'...«s�''�al�'1l itji�i\ t: '�r'''',�*1rS71 •s'•_b,'.+,':.s•',.�••'"'••:_r'' '!''r•,.ty•._.r,s:•",�5i'"..:'••liS i.:•l N J T.},i.",v''••iij:t',J1,,1:'��'12:t1r:j:s,.•..•r.-�i':t'''.'!'r_'�•.•?'�:l7i:ry.:t...i.r'+.t••ati=i�l,,, •�:r,"•4'1<�emet id'regs: 1. :"•''• ..::'; �• ; •::i •a: s t. rI , '' a••:rt. r. 5�,:%i; a•n..:;t,�.• rt'^,'E.:.�.r••,4:t t• • ,'I { .is .:5.,:"'fir,,".,.•�r'Efa tt,.::��' .,,,�.l:+S:itJ�ti>;ii' r"'r,si:..r'.r:t... •'../ .. :�':••.I• , •L , t•y"h:• .'f• j''F .t'•t:` r',=' •• 43one.•#r::, -S: ••• • , ' •• .t�. , �'''', .\�.t/ , �i• :r ..^i�' <<t•r • •'l- ,j •t 1:•... :.. :Ii"'' }['• :�'�r 't.::''S't. .1uC .4i•'tf iL:=t?• 'L• •'t 4 t, - •' i,L,.:;7••' •t tt{': ` ••1 '�,�••'' .'. '4r.1' •' ,_ '' YT w•: {••'J'.,%..• ii 'r yr• •i.sic r�=;:y tr.'• G:JJ E,''r.4' .I •,i'S=: ._ * : :.•..•:•• irisuralice.c'o"l,..• :'=;.: . .:.., • .., .: I am a sole proprietor and-have hired the independent contractors listed below who have the following workers' mpens tion polices: \ ll •:_ ,ir .; .+, :I•:', S��',Lt:,�q�:�{;�'sr.•A2��:��,`f,�;rr�t?.:y=' ii�:. :�..:.� •, `•y,�(�,I. L. ::�,.,y:^i' •.��.•',\ t•�..y.•� t.,. • .o ' �••" ei •f r:' :nit .•11alLCi,. •1•:t. - •'. .•.: { i •P.Y• r •'v'�•, _'�.•• r • C, 9n Y '4' x, ,ii" ::.1•li rti :°' S' I•r .: 1 t:.;F,�` nti�'':;�: :t'. 'T:ti,Lc i:ir {�,r.J•:,{•. ''i S., Si•.J'f t " t• ..j••l' _•" S• •r''rir'. •:�� .'�..':•nt'•}•'' 7 ''' j r •:+�, r •'' 't'•'= 1. :LiCi ,t,a•,hti:..r� 'i'' T '• tiy� r r:• 'i':' 7•'r•'t:l :rr•.':.` '_'• 8�ldgeSS'..t' '`' ��; %' ;`•,r•4r; r. . ; 'ri: 11=., r•:;t' •r,l: :.r.. t �,. ,'• ''•: \ r .t . P 1•"''•'(i{'I' �.1 hL 2•• r (•:''t• i+rl•\;iJ,r : .�.� 1. 'rt•�,I''•'.4�,r•5: ' •r: '.Y'a'•:.. ri,• :t.r••k S;'."+r:' ,. +,,,. •t• i ; 'ti• _.t.. '' :2'= �• 1. •I.s• \' t. 1.i _ „••. S4. i,.^tiw.,l 1..:; �•;rr{r'.;r{>.il •it'd:: +Z}:,,h:a�,�•;,••', •ri` -t�j' °t�<i:: °T .,'•.t; r••5:, .,�r r ti' S: "j •, v:t:t:• .1, '�"�r.• e;,.':t:rr,:': •'. S >,r: ': ':1:' �••i. 42 ^r ram:.••-��:-a ty, s.`{.`i.,e,. •� r;: J+,,,,••;' '. �,'t,',,.•' ••x +''.s�,.,.ws1�s} :.t t, '}:. ..,;••.r'.' •f0'1le =#� r,}f:tti::y7•. .l• . . •.. f ,.• ~�'•�,.y hWL.;s9-:,,J�•{,..tl'r• r.�P�•.,•. -$;y.y bin; •S:J't:.• .. �����///�/////fi, / I el ' .; ,.. •. ••{•:' i'r:,, :1:•'' Sn4'Ii:r •i ,•t':' ':•: .�= r;'=: ..rJty t,:y •(.•J'1 yt:'1•:•r.t';�°P`•: '.:�i.if, ,. L_ .{(,i,: .:p °•I =il'+••'J'�'1•Jni •, .:t..- r•fr,.:•' 4•. '(. 1:n.,,rt 4Aa•.r Gip t••\},, �,.•,.r;,rf.ui' ti :�..'_',�,\�• •�'•.t•' I 'Y. • .th ''' T' L!r'•`1"'' !u�•=•• ''L I• •.\ ;.,,. 1.`}. r.=.:t,.n•. „ .••l..,J:i:.:S �s GSf: ' ':ta.r•Cl.,,n:•'R:' :i: ':`:.t` •ir d•.t.�'':ti�r...s. '�' .. J. .i t,• .. �• r t'• ".T»+'�2; coin an• nanie:•a , .. - ,!l. .��. �! ' , _. •` '� . • i• ,l .. ' •�j'• 's• s •:' ' '•• '' `• .:,.�:, �V e:•';'•��':•' �1•�;'1.=•�'t�•t'•;�.?::J'^, .i, 2 es CI ,• •,r' •dr '� ;••,.i5,� As1 'g n•}- •i•. .�,:•,:ui:�s2' yr''• ' ,'i• a `,� i • .��,. •:i}4•. '' '�•Z�' '''t:t• •; ..� f ,s ••s:! J• r'.v .s ,t:., t•._'%" .Oil'rl��sf K.! 'a',iK 'rt7' •i s'• s• t• ". 1 i .t', .'�•.• .r. :;jyr:•`r {.'i 1'y ,.S'!.q' OZIC. _•' �� i d A. ��'.+,l i''r;, ':J• ''M� - iiisu'ranc l of it ne Failure to secure coverage as required under Section 25Ao of M e 6TOP WORK ORD152 can lead to the E$nd a fino of 5100.0 a day againstt me. I understand that one years'impri'onment as well as cfvllpenalties the form copy of this statement maybe forwarded to the Office of TnvrsBgatio the DIAfor coverage verification 7 do herWber th0. enaltie er at the .A ormadon provided above is true and e rr� Date y ' Phone# Print name - official we only do not write in this area to be completed by city or town official permit/license# []Building Department city or town: []Licensing Board ❑Selectmen's Office [}checkif immediate response is required []Health Department , phone#; []Other contact person: (tevned Sept 2003) - --- - Information and Instructions. General Laws'chapter 152 section 2.5 requires all employers to provi$e•workers' compe�nsatidh for'their. Massachiisett� "'`' employees: .As quoted'from the f`law", an employee is.defined as every person in the service o another undo any contract Of hire;express or implied; oral or written. employer is defined as an individual,partnership, association, corporation or other legal entity, or any two or mgre of An the foregoing engagod•in ijoint enterprise, and including the legal zep rresentatives of a deceased,employer, o''the-receiver or partners association or other legal entity, employing employees. 'Howevei.the owner of a trustee of an individual,p • p, dwelling house baving.not'inore than three apartments and-who resides therein, or the occupantbf the dwelling house bf another who emplbj -Persb�to do maintenance, construction or repair work on such dwelling house csr on the grounds or -building$ppin tenant thereto shall not because of sucliemploymeat.be deemed'to be;ari employer. MGL chapter.152 section 25 also"states thafevery s°tate'or legal Ucensing-agency shal`i$rithhold the fssuaneb or renewal of a license or pen*to operate a business or to construct buildings in the.commonwealth for any applicant who has not produced acceptable.eyidence•of compliance with the insurance coverage required.' Additionally,*neither the' coix,monwealth nor.any.of its political subdivisions shall enter into any cottract for the performance of public work untq acceptable evidence of compliarice with tie insurance rbquirements of this chapter have been presented to the contracting.. authority: Ell New Applicants Please fr the v�orkers'•eonpensafm a€f davit ccmnpletely,by checking the box that applies to your situation.•Please supply company name, address and phone numbers along with a certificate of insurance as all affidavits may be submitted to the Depapanyn.kr Industrial Accidents-for confirmation of insurance coverage. Alsobe 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 thO law"or if you are obtain a workers.'•compensationpplicy,please call the Departii=t at•the number listed below. , required to . , City or Towns . cbmplete anclprinted legibly. The Department has provided a space at the bottom of the Pleas ebe sure that the affidavit is affidavit for you to fill out in-the event the Office of Investigations bias to contact you regarding the applicant. Please e to fillip the permet/licensa nee•.wbich wM be used as a reference number. The.affidavits maybe returned tq, be sur ... •t have been ma de. `FAX unless other arrangemen s a .. . the Department b�,mail or . . , you in advance for you co eration and should you have any questions, lions would like to thank y y op The Office of Iuvestiga ,. • .. . please do nothesitate to give us a-calL• The Department's address,telephone and fax number. , The Commonwealth Of Massachusetts- Department.of Industrial Accidents Dfffce of Wtesiil ONS 600 Washington Street gt Boston,Ma. 02111 fax#: (617)727-7749 oFt r Town of Barnstable Regulatory Services MUMSTABLE, : Thomas F.Geiler,Director y MASS. 1639• �•�a Building Division TFD MA'I Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street ,/p / /U villa"HOMEOWNER": L L! �I. f (�� �B �� / 7� /� ,�, 3sr_ 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. DEtiNmON 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 a/she understands the Town of Barnstable Building Department minim ction procedures and re ents and that he/she will comply with said procedures and r e e ! a 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 Parcel Detail Page I of 2 { S a m.. 41 : Logged In As; Tuesday, May 4 2004 Danielle St.Peter Parcel Detail Home Application Center Parcel Lookup Parcel Info Parcel ID 327-227 Developer Lot Location 29 LEWIS BAY ROAD Frontage 70 Sec Road Frontage _.... ...... ._.._......... Village HYANNIS Fire District HYANNIS Owner Info Owner 1TAYLOR, WILLIAM H Co-Owner Streetl `29 LEWIS BAY RD Street2 j City jHYANNIS State jMA zip 02601 Country �� Land Info Acres 0.28 mm Use ;Single Fam zoning PRD Nghbd 0107 Topography Level Road Paved Utilities IAII PUl Ikc Location I- Construction Info Building 1 of 1 .,.,A,,..... .� � Year 1930 Roof,Gable/Hip AC None Built Struct Type : Effect 1984 Roof `As �h/F GIs/Cm Bed 4Bedrooms Area Cover p Rooms is ---------al �--- - nt Bath Style Conventional Wall ''Plastered Rooms 1 1/2 Bathrms - x ; Total Model Residential 8 Rooms Rooms Bath Grade .Average _ Floor Pine/Soft Wood style ' Stories Kitchen 1 1/2 Stories Style Ext �,.x,.......�..�,-m,,,,��AA,�,•„G•• Heat .._ -� .,,,•� - Bath �._._.,�,.m, waII .Wood Shingle Fuel toil split 1 Full+ 1 H Heat Hot Water ' Found- Type anon I Poured Conc. Permit History Issue Date Purpose Permit# Amount Insp Date Comments Visit History _ Date Who Purpose http://issql/intranet/parcelinfo/ParcelDetail.aspx?ID=27678 5/4/2004 r Parcel Detail Page 2 of 2 2003-04-09 PT Meas/Est 2002-05-09 , PT Meas/Listed 1 Sales History ....r.... .._.. Line Sale Date Owner Book/Page Sale Price 1 11/8/2002 TAYLOR, WILLIAM H 15887/238 $285,000 2 2/25/1969 MORELAND, JANICE A 2005/100 $0 -- - .......... .... ___.------------..._......_.- .............. ___------..m._....... ...... Assessment History Save# Year Building Value XF Value OB Value Land Value Total Parcel Value 1 2004 $104,800 $0 $4,500 $164,000 $273,300 2 2003 $94,900 $0 $1,400 $27,800 $124,100 3 2002 $94,900 $0 $1,400 $27,800 $124,100 4 2001 $94,900 $0 $1,400 $27,800 $124,100 5 2000 $78,900 $0 $700 $23,100 $102,700 6 1999 $78,900 . $0 $700 $23,100 $102,700 7 1998 $78,900 ' $0 $700 $23,100 $102,700 8 1997 $84,000 $0 $0 $23,100 $107,400 9 1996 $84,000 $0 $0 $23,100 $107,400 10 1995 $84,000 $0 $0 $23,100 $107,400 11 1994 $84,000 $0 $0 $48,500 $132,800 12 1993 $84,000 $0 $0 $48,500 $132,800 13 1992 $95,600 $0 $0 $53,900 $149,800 14 1991 $95,900 $0 $0 $76,900 $173,200 15 1990 $95,900 $0 $0 $76,900 $173,200 16 1989 $95,900 $0 $0 $76,900 $173,200 17 1988 $55,700 $0 $0 $60,800 $117,100 18 1987 $55,700 $0 $0 $60,800 $117,100 19 1986 $55,700 $0 $0 $60,800 $117,100 Photos http://issgVintranet/parcelinfo/ParcelDetail.aspx?ID=27678 5/4/2004 _.. - - _ - - - - Drainage Notes DPI O 6 Dza_ x 4- 1 , EM/D ep-th Total BuildingUse - 1,900 s .ft. H2O load precast leachingit set in q 10 L x 10W x 4 - Eff De th it Dwelling Use 1348 sq.ft � ,' .� F P g of 3 4 -1 1 2 Washed Stone., r / L. G NT Office Use hi o (C r pro c tic) 552 sq.ft. � w " Metal frame and grate mortared .atn r; '� CB Existing Contour _--34--_ P 4 El 32.56 Proposed Parkin Spaces = 6 ¢ � G - - in Place Rim St ' si ss (Rim set 2 above parking fin. grade) FNl? P g P P s �, c� n Proposed Spot EleY 34.4 p u DP,2 =: (1) 500 gallon H2O load precast 14> .leaching. chamber Proposed Building Light , F car set in III x 7'W x 3' Eff/Depth pit a ' " SMAI of 314I-1 112 washed stone. Proposed Dryw-el1 y 1) iy Way r Metal frame and grate ,mortared in Place Rim El 32. 72' Existing Spot L'le� 34.4 , tutiuH ^uaS[S +. J Existing & Proposed Drainage Flow ct x DP3 = (1) 6 Dia. x 2 Eff/Depth 'MANN' ' trt' `a H2O load precast leaching pit set Proposed Drainage L acne • PFlow w one foot of 3/4 -1 1/2 Washed Stone. � ° " 'V ass Vehicle Bumper Stag etal f n t M frame and grate. mortared Lc:> C' T T,:E3 M.AP' in Place Rim El 29. 72 Deciduous Tree �r 0 RI .• m El. 2 651 / N F`� �fICII,gLL J BL"FMER LLIAltf ARCHIBALD .fi Rim El. 26.30 O .�i Bandic,a R.Cj rn ca fi ,: 34 P Design BY others Existing :5834527 CB �"-----_._. hers , 'E' �'. 81.80 FND. Pa vem en t r� 33 32 31 ., PARCEL 227 q 7" 12,575fsq.ft. � xistrrig --- ` 27 GRAPHIC _ SCALE fi 5' -- - Garage �� Existin r 26.59 as / g Pa ve -` . ,ti d •Drive wa r � .. . so., 0. ,0 20 40 80 1344 fi - alk i 1 Propsed _. .. _ { ;IN FEET r� _ .- t .. . . ,. , Ole ti _. P ...._. Gra vel �� � r : �.,� . � i inch = 20 ft. v im El 26.15 W ParkingCD q� .'' , i r •, p q 12 b 1 _ ,: 4 Wide i i lz� 4 I>P1 3 ,. ;. EXISTING DWELLING ' - 1 O ...........: ► PRO F'PSED�' r ;... , ,/, . . , . . . . . , . . , ca OFFICE USE Exzs Rim .0 4 -8 • + `' 44 tzng Walk 'l 2 6 9 330,1 + Ve n 34 � V r1 34. Public RECEIVE 66 33 p + __ f� � r c 5'0 CB 83 52 .. - r j � ` FNI) / ~ .:�_.._ MAR 1 2 2004 s 8 _ ,. 31 ��� � ed e_ ,q _�- �' of_--� S g5 ex t ».. �`--- rsti � l n Rim 33 , ,,,,._ Q Q TOWN OF BARNSTABL A rnern t 32 r 30 .. 11r8320 5 E126.57 SITE PLAN REVIEW NSF -- Ulpole �'WIS BAY , ROAD C01YD© -2!il �Nru� �' -: �. a. d Prepared For- Existing p .. Pavement Wi lIa a W—E X-11 In _ Hyannis, Massachusetts Locus Address J. �^ Scale 1**' = 20' Date: November 2, 2003 29 Le wis Bay Road CK)YL 37 , Prepared By»• Assessors Map 3,27 Parcel 227 Stephen J. Doyle and Associates ; _ I hereby certify that the structures.are shown k 42 Canterbur l' Lane, E Falmouth, AfA 02536 _ Telephone a Reference Deed. : 5081540-2534 n the plan as they ex st the ground. ty , Book 15887 Page 23 t-t • z •ate► g 8 „ o{ �r R -vim' i t�z- _ 1F.3 Z C> Date Professional Land Su veyor c 2- FEYA Data: Zone "C jf�./r W 1AV Zoning Dist w scr ,• v 't � k� Sip 41G 27.30' 2 _ 6 91 2 ?� 1 02 ,24 04 add DP3 V N .0 DATE DESCRIPTION 13Y i i Drainage Notes DPI _- (1) 6. Dia. x 4 Eff/Dep th Total Building Use 1900 s .ft. P I H2O load recast leachingit set in q 101 x 10;P W x 4 Eff/Depth 'pit Dwelling Use = 1,346 sq.ft _ k , of 3/4"--I 1/2" Washed Stone. Lam'G E NIA Office Use ) q(chiropractic) 552 s ft. P *� Metal" frame and grate mortared sJ ¢ e"Y in Fla Rim EI. 32.56' CB Existing Contour --34--- st 3 FirD. Proposed Parking Spaces = 6 (Rim set `2" ,above parking fin. grade) Proposed Spat EleV X pres 34.4 4 DP2 = (1) 500 gallon H2O load t , leaching chamber . Proposed Building Light Cosset in 11'L,x 7'W x 3' Eff/Depth pit 4JSJTAL " Proposed Drywell way of 3/4 -1 112 washed stone. + . �,., J , Place i l grate Existing Spot Metal frame and rate mortared Y•��,F In 1 Rim E 2 Ele v. 34.4 ti �uJsrs IfAU Existing & Proposed Drains n a z DP3 = (1) 6' Dia. x 2' Eff/Depth e Flow'g trrrax,+, ` `a H2O load recast leaching it set c y WPDt + >, P g P Proposed Drainage Flow ..�► tW rt ➢"�ic ^. 1 ti g � ° , ,. one 'fast of 3/4"1 1/2" dashed Stone.. I QAW � � � � �R. ; +���; ;;, Vehicle Bumper Stop Wes. 29. 7 -. CDC' �� in Place R'm tal frame �E` 2 mortared Deciduous Tre nd grate� e Rim El. 26.51 .N/f' MICf{AEL �' ti BLL'�'ffER - N/F o A Afc'CfIfBALp J4 Rim EL 26.30 � ffandlca Ramp De W 34 �-- I�n By Others Existing SS83V5;27" `� CB Pavement 81.80 FND. " 33 32 31 q 7� PARCEL 227 E `` `, q ► °7" 12,5751sq.ft. x�'stjng �, -----__ 27 GRAPHIC SCALE -� _ 26,59 5 Garage � Existing pave so ,o 4 1344 28" _, y 26.6,e' -- f to Proposed f :...... ... ... i f 1 ale IN FEET -- itrl E1.26.15' 1 inch - 20 '#t. � q ' Gra vel � � b�' .. sP t- --- W Parking , '~�`� ; ; o q 12" -=-- to DPI 4ti Wide R, �p - EXISTING DWELLING ( /47TH PROPOSED, 4 8" ,� _ 44' HOME-OFFICE USExistzr! Rim El J26.09 �.� , 4 -- 8 Walk Pa Ve M . EAS .. 1 8t 66 33 .� 34. , r / ' Public - 50 ode CB: -5835Ry3" cri .' ---�� `' i I E FND. E 6" 8" 6 _ ' ' 31 �"(�-ems-- ' �A /� A edge _ r �V � ��_ /! MAR +1�`} � - Rim --.....o f-.�.existirr 33 � �' , ----pa Mernent _:,_. .. . 32 ,_._ , 3 N83``.,"�.-",�, El. 57 � . 20 53 yy TOWiv O -AR d u/pole SITE PL..' , ,. ;, k -„ N/F LE'#fs' Sit le Pl a X2 ca f L n BAY ROB CONL7O.rtillNlU.Af � c`� C:Z Pre ared Fot~ I P C or- Existing Pavement - 11:Z- a � Wia 7-7 In 1 a n l s Massachusetts • � y n Locus Address �; J. �' Scale 1 = 20 Date: November 2, 2003 29 wis a Road t CYYLe Le Bay R � R 37 Prepared By R Stephen J. Doyle and Associates Assessors Map 327 Parcel 227 �� :.. .��1 ` �. 3 P y ,•�. 42 Canterbur Lane, .E' Falmouth, MA 02536 l hereby certify that the structures are shown p .Reference Deed.- Book Telephone: 508/540-2534 on the plan as they ex st the ground. `'� -t. • t'>•.^r Book 15887 Page 238 Igor W4 R -v-i G7 1` B.Z v CZ-- Date Professional Land Su ve or ,� " y FEMA Data: Zone C �a, �Mlti.M s All Zoning District: PR u MO. 131171a H c Q``�ti� fsSrp s t�G'� U O Z , 27.30 26.91 Z rq) v 1 02 24 04 add DP3 NO. 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