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Town of Barnstable Building
t IPost This Card So That it is Visible From the Street et-Approved Plans Must be Retain_ed on Job and this_Card Must be Kept
Posted Until Final Inspection Has Been Made. PermitJWhere a Certificate of Occ163
upancy is Required,such Building shall Not`be Occupied until a Final Inspection has been made._
Permit No. B-19-791 Applicant Name: Wojciech Piwowarczyk.
Approvals
Date Issued: 03/15/2019 Current Use: Structure
Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date- 09/15/2019 Foundation:
Location: 71 MAPLE STREET, HYANNIS Map/Lot: 310-368 Zoning District: RB Sheathing:
Owner on Record: BARNSTABLE HOUSING AUTHORITY Contractor Name >.,WOJCIECH J PIWOWARCZYK Framing: 1
Address: 146 SOUTH STREET Contractor License., CS-076146 2
HYANNIS, MA 02601 "`, n Est. Project Cost: $ 15,500.00 Chimney:
Description:• Roof replacement at Scattered sites ( Permit Fee: $79.05
i Insulation:
Fee Paid:' $79.05
Project Review Req: r
Date: :` 3/15/2019 Final:
Plumbing/Gas
Rough Plumbing:
I Building Official
Final Plumbing:
This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance.
All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted.- Rough Gas:
All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes.
This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of.the Final Gas:
work until the completion of the same.
-
_ Electrical
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this'permit.
Minimum of Five Call Inspections Required for All Construction Work:, Service:
1.Foundation or Footing
2.Sheathing Inspection °" Rough:- .
3.All Fireplaces must be inspected at the throat level before firest flue lining is installed
4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final:
5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough:
6.Insulation
7.Final Inspection before Occupancy
Low Voltage Final:
Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health
Work shall not proceed until the Inspector has approved the various stages of construction.
Final:
"Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A).
Building plans are to be available on site Li_t'AA-
Fire Department
All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Final:
S�j
z 7
s
Cape Save Inc. `GOWN QF 'RUIS f E L '
7--D Huntington Avenue , , -,
South Yarmouth, MA 026dJI3 NG 2 0
Tel: 508-398-0398 Fax: 508-398-0399
11/24/13
Town of Barnstable
Thomas Perry CBO
Building Commissioner
200 Main St. Hyannis,MA 02601
3
RE: Building Permits
Dear Mr. Perry,
This affidavit is to certify that all work completed for 71 Maple Street,Hyannis has been
inspected by a certified Building Performance Institute(BPI) Inspector.
Ceiling: R-30 cellulose
Basement: R-30 fiberglass in overhang and R-19 fiberglass in box sill
All work performed meets or exceeds Federal and StateRequirements.
Sincerely,
William McCluskey
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
Ma 3 O Parcel 3 6 B licatilon'� 101 �3
p `Alp
Health Division Date Issued
Conservation Division Application Fee
Planning Dept. Permit Fee t
Date Definitive Plan Approved by Planning Board
Historic OKH _ Preservation/ Hyannis
Project Street Address 1 M a n e__. S't'
Village 4100AtS
Owner �owIt tk� o Address STI, 41AAAIf
Telephone
Permit Request celky tole- to '
i-o rt�� �ws�nlon�. erase QAck gills WX R' 13 mll 1AUP. 14 seai
J6 a, ,c )Damoni, W i i M
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 ❑ Two Family ❑ Multi-Family (# units)
Age of Existing Structure 110 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 baths): existing new First Floor -Q County c�
Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other k .
Central Air: ❑Yes ❑ No Fireplaces: Existing New Existing wood coal stoJ : ❑.Y�s�❑ No
Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑existing new size_
Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: "?
Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑
Commercial ❑Yes *No If yes, site plan review #
Current Use Proposed Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name 411 f�dl mcom��C� Telephone NumberJ(1g 39 b o3 Ia
g
Address e;-,-. License # C to
ScAn fmdv.A Home Improvement Contractor#
Worker's Compensation # TU C. 3 3 53 9 6$
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO Yo�rihou '�
SIGNATURE DATE b 3
FOR OFFICIAL USE ONLY
APPLICATION#
DATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
FOUNDATION...;;,,;
FRAME
INSULATION
FIREPLACE
ELECTRICAL: ROUGH FINAL
PLUMBING: ROUGH FINAL
r
GAS: ROUGH FINAL
,r
,f FINAL BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO.
i 4t 460 West Main Street
Housing Hyannis, MA02601-3698
Assistance Tel: (508) 771-5400 Fax(508)775-7434)
TTY on all lines
Corporation r .
Cap cod
Free Weatherization ..
Your tenant has requested and is eligible for weatherization of your rental home
through government funding. This will be provided at no cost to you. Program
regulations permit us to spend around $4,000- $10,600 in materials and labor per
dwelling unit.
Program regulations require us to weather-strip and caulk doors and wiirdor-s; insulate
attics, sidewalls and floors. All work is professionally done by established private
contractors. We will conduct a final inspection to make sure that all work is completed
to specifications.
If you request, you will be informed of the estimated measures.be fore they are done
and provided with a list of the actual measures and costs following the completion of
the work.
We also need proof that you own the property. A copy of a CURRENT TAX BILL OR
DEED listing you as the owner will satisfy this requirement.
Please fill in all blank areas of the enclosed agreement and return with the proof of
ownership as soon as possible.
If we do not receive the enclosed form within two weeks, we will do a basic
energy audit of the home, but no wieatherization work can be recommended or
done.
If you have any questions please call Ruth Bechtold at 508-771-5400, ext. 102.
LANDLORD: TENANT'
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Email: kr —P�*i' `�&t. barns(a.hdo:.uzr,a us
email:
PHONE — T2� ,�- PHONE a 3
TENANT/PROPERTY OWNER/AGENCY WEATHERIZATiON AGREEMENT
1. The Parties to this Agreement are the following:
(hereafter known as Tenant),
(print your t nant's name) (,
'&-w4v" Aulimel
' '�. A' I (hereafter known as Property Owner)
(print your name)
and Housing Assistance Corporation (hereafter known as Agency). In consideration of the mutual promises
hereafter stated,the Parties agree as follows:
2. The date of Agency's signature will be the effective date of this Agreement.
3. Property Owner and Tenant consent and agree that the Agency may do the following with respect to the property
located at (street,town) '
T ila l S , unit# , and currently leased or 'rented to the
Tenant: `
a) Enter'the premises for the purpose of per, rming a Weatherization.inspection.
b) Enter the premises to perform Weatherization work which the Agency determines in its discretion is
necessary and appropriate as a result of the Agency`s inspection of the property and in accordance with
the appropriate priority list for the type of dwelling. The Agency and the Agency's contractors may also
enter the appropriate common areas of the building for the purpose of accomplishing the Weatherization
work. The Agency and representatives of the Commonwealth of Massachusetts, Department of Housing
&Community Development(DHCD) may further enter the property to inspect any and all work
hereunder. The Agency will provide reasonable notice of the timing of the Weatherization work and
inspe..ctions. The Weatherization work will be performed in accordance with the Property Owner's
consent as further specified below:
***INITIAL ONLY ONE OF THE FOLLOWING"**
I c sent to performance by the Agency and its contractors of any Weatherization work determined
cessary and appropriate by the Agency as a result of Its inspection of the property. I understand that
the Agency will provide a detailed statement of the actual work performed and the associated value at
the completion of work.
I will provide a separate consent to performance by the Agency and its contractors of Weatherization
work following my receipt of the Agency's inspection report and a statement of the estimated work and
associated value. This additional consent will be sent under separate cover as Attachment A. I
understand that the Agency will provide a detailed statement of the actual work performed and the
associated value at the completion of the work.
4. The Property Owner understands and agrees that any and all work, including related repairs for which the
Property may also be eligible,will be performed at the Agency's discretion. The Agency estimated completion of
the Weatherization work by the end of 2013.
5. If the Property Owner is required to make repairs to the property prior to the commencement of Weatherization
work by the Agency,the Property Owner will be notified by the Agency and will be required to make the repairs as
soon as possible. Except where the Property Owner receives a written extension from the Agency,time is of the
essence in the performance of repairs by the Property Owner,
6. The Property Owner and Tenant authorize the Agency to receive a statement from the fuel supplier/utllity supplier
as to the quantity of fuel/utilities used at the above address in each of the past three years and the future three
years. The information is to be used only to determine the cost effectiveness of the Weatherization
improvements.
7. The Property Owner agrees that the rent for the dwelling unit will not be raised because of any increase in the
value thereof due solely to the Weatherization work performed.
r 8. In consideration of the Weatherization work hereunder,the Property Owner further agrees that upon the effect€ve
date of this Agreement and during a period extending through 2013/2014,approximately one
year from the time the work is completed,
a) The present rent$ ill not a raised for any reason. (The rent amount must be
filled in). Heat included€n r nt. es.__ No
However,'this Paragraph(8a)will be waived by the Agency In writing if,and only if,the premises
are leased under a state or federal rent subsidy program, In which case the actual rent charged
by the Owner shall conform to the standards of the rent subsidy program.
Please state which Housing Subsidy program your tenant is on and through which Agency:
a J
b) The Property Owner w€ll not institute any summary process action for possession except in the case of
non-payment of rent or other good cause related to the Tenant(or any successor Tenant).
c} In the event the Property Owner decides to sell the premises, Property Owner shall comply with one of.
the two requirements below:
--The Property Owner shall not sell the premises unless the buyer agrees (with a copy forwarded to the
Agency) in writing prior to sale to assume all obligations of the Property Owner set out in this
Agreement; or
--The Property Owner shall pay the Agency an amount equal to the cost,as certified by the Agency, of
the Weatherization materials installed and labor performed in the premises as of the date of sale. Said
amount shall be paid to the Agency immediately upon sale.
9. (Applicable only if Tenant's heat Is Included in rental payment and blanks are filled in) At the end of the
period set forth in Paragraph 8 above,the rent shall not be raised more than . %per for an
additional period of one year, and the provisions of 8b and 8c above shall continue in effect for such period.
However,the rent provisions of this Paragraph 9 may be waived by the Agency in writing if,and only if,the
premises are leased under a state or federal rent subsidy program, in which case the actual rent charged by the
Owner shall conform to the standards of the rent subsidy program.
10. The Parties agree that the terms of this Agreement are incorporated into any other lease or agreement between
the Property Owner and the Tenant, and between the Property Owner and any successor Tenant, and if there is
any conflict between the provisions of this Agreement and the provisions of such other lease or agreement,the
provisions of this Agreement shall govern. However, if such other lease or agreement, including without limitation
a lease or agreement under state or federal rent subsidy program, contains stronger protections for the Tenant,
such stronger protections shall apply.
11. For breach of this Agreement by the Property Owner,the Property Owner shall reimburse the.Agency in an
amount equal to the cost, as certified by the Agency, of the Weatherizabon materials installed and labor
performed on the premises,as well as attorneys fee and court costs. The Property Owner may also be liable for
damages to the Tenant In accordance with applicable law; in such instance, the Property Owner shall reimburse
the Tenant for attorneys fees and court costs. Without limiting the foregoing,the Agency may at its option
terminate this Agreement,by providing written notice to the Property Owner and Tenant, in the event of breach by
the Property Owner or Tenant.
12. Performance of the Weatheftation work hereunder by the Agency is contingent upon the availability of funds to
the Agency from the commonwealth of Massachusetts and the federal government,as well as the eligibility of the
Tenant under WAP program requirements. The Agency may terminate this Agreement,by providing written
notice to the Property Owner and Tenant, if the Agency determines that the unavailability of funds or ineligibility of
the Tenant warrants termination.
13. 'The Parties acknowledge that this Agreement is under seal. It is intended by the Parties that the Tenant or any
successor Tenant is the intended beneficiary of the Agreement and shall have a right of enforcement.
Property Owner's Signature: f Date 0 13)
Phone:
Address:
140 8OUTH
W MAi f
1
Tenant Signature
Agency Approved Weatherization Company
Cillp SIX
r ,
All Cape Energy / Adam T.Incorporated / Cape Cod Insulation Cape Save /
Frontier Energy Solutions / Lohr&Sores Inc.'/ Resolution Energy
Agency Signature Date'
The Commonwealth of Massachusetts
4 Department of Industrial Accidents
Office of Investigations
1 Congress Street, Suite 100
Boston,MA 02114-2017
* ` www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibi
Name (Business/Organization/Individual): Cape Save Inc.
Address: 7D Huntington Ave
City/State/Zip: South Yarmouth, MA 02664 Phone #: 508-398-0398
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 1 6 ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
listed on the attached sheet. 7. ❑ Remodeling
Z.❑ I am a sole.proprietor or partner- ,
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.]
S. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
,.❑ I am a homeowner doing all work
officers have exercised their I I.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL c.
Roof repairs
insurance required.] t c. 152, §1(4),and we have no
q ] employees. [No workers' 13J71 Other Insulation '
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy infonnation.
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 ain an employer that is providing workers'compensation insurance for my employees. Below is the policy andjob site
information.
Insurance Company Name: Technology Insurance Company
Policy#or Self-ins. Lic. #: TWC3353968 Expiration Date: 04/09/2014 ,
Job Site Address: -t" A lL � City/State/Zip: 0.n(� 5
workers' com nsation policy declaration page(showing the policy numb�xpiration date).
Attach a copy of the p p Y
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 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.
1 do hereby ceo&under the Pains and Penalties ofPedoAy that the in orination provided above is true and correct.
Signattire: Date
Phone#: 508-398-0398
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#:
ATE
.4co CERTIFICATE OF LIABILITY INSURANCE 10/22 D /22 f/2013013'
THIS t ERTIFICATE 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(les) 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 NAME:NTACT Colleen Crowley
Risk Strategies Company PHONE (781)986-4400 FAC No: (781)963-4420
15 Pacella Park DriveE-MAIL
Suite 240 INSURER(S)AFFORDING COVERAGE NAIC S
Randolph MA 02368 INSURERA:Selective Ins. or America
INSURED JNSURER B:Safety Insurance Company 3618
Cape Save, Inc INSURER C:Technology Insurance Company
7 D Huntington Ave. INSURER D:
INSURER E:
South Yarmouth MA 02664 INSURERF:
COVERAGES CERTIFICATE NUMBER:CL13102268490 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.
LTR TYPE OF INSURANCE S POLICY NUMBER MO ICY EF DDFYYYY) MPOO!ICY EXP LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ED 100,000
A CLAIMS�vtADE a OCCUR 1994480 0/16/2013 0/16/2014 MED EXP(Any one person) $ 10,000
PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: r _ PRODUCTS-COMP/OP AGG $ 2,000,000
POLICY X JECT PRO XLOC + $
AUTOMOBILE LIABILITY (Ea COMBINED
I ED N L uM 1,000,000
B ANY AUTO BODILY INJURY(Per person) $
ALL OWNED X SCHEDULED 208200 1/6/2013 1/6/2014 BODILY INJURY(Per accident) $
AUTOS AUTOS
X HIRED AUTOS X AUTO NON-OWNED PPerracadentDAMAGE $
X UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,000
A EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000
DED I I RETENTION$ 9I 1994480 0/16/2013 0/16/2014 $
C WORKERS COMPENSATION Officers Included for X VrCSTATU- OTH-
AND EMPLOYERS'LIABILITY YIN 0 I
ANY PROPRIETORIPARTNERIEXECUTIVE overage
OFFICER/MEMBER EXCLUDED? N❑ NIA E.L.EACH ACCIDENT $ _ 5OO OOO
(Mandatory in NH) 3353968 /9/2013 /9/2014 E.L.DISEASE-EA EMPLOYE $ 500,000
If ins describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT '$ 500 000
e k
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required)
Weatherization Specialists
GL: Blnkt AI, Blnkt PNC, Blnkt WOS Per Proj Agg, Per Loc Agg / GL Exclusions: Snow & Ice
Removal/OCIP/Wrap Ups
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.
AUTHORIZED REPRESENTATIVE
chael Christian/CLC
ACORD 25(2010/05) ®1988-2010 ACORD CORPORATION. All tights reserved.
INS025(201005).01 The ACORD name and logo are registered marks of ACORD
F r
Massachusetts -Department of Pudic Safety
Board or Building Regulations and Standards
Construction Super-i isor Specials
_icense. CSSL-102776 `
WILLIAM J MC C-LUSKEY,_.
37 NAUSET ROAD ,
West Yarmouth MA 02673 ?._
Commissioner 06/28/2015
Office of Consumer Affairs and eusness Regulation
r 10 Park Plaza- Suite 5170
. Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 171380
Type: Corporation
Expiration: 3/14/2014 Tr# 222184
CAPE SAVE INC. -
WILLIAM MCCLUSKEY,
7-D HUNTINGTON AVENUE, -
SOUTH YARMOUTH, MA 02664
Update Address and return card.Mark reason for change.
17, Address t� Renewal (J Employment Lost Card
)PS-CA1 0 50M-04/04-G101216
71,e Taa7wtnoouaea a� l�cz�aacluJet�a License or registration valid for individul use only
\ Office of Consumer Affairs&Bdsiness Regulation. g y
C� 7_HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration -171380 Type: Office of Consumer Affairs and Business Regulation
s-V 1 Expiration 3/14/2014 Corporation 10 Park Plaza-Suite 5170
Boston,MA 02116
mac.•�...� � - ,
CA SAVE INC.
WILLIAM McCLUSKEY =
7-D HUNTINGTON AVENUE' a,p _
SOUTH YARMOUTH,MA;0g664- Undersecretary Not valid witV6)Ft signa
Engia e'ering Dept. (3rd'floor) Map
310 Parcel (oq 3 _ Permit# ' a*-
House# 7 J �� Date Issued
fiBoard of Health(3rd floor)(8:15 -9:30/1:00-4:30) i Fee ; S -
Conservation Office(4th floor)(8:30- 9:30/1:00-.2:00)
Planning Dept.(1st floor/School Admin.Bldg.)' iNE
Defi ' ive Plan Approved by Planning Board 19 '
_ BARNSTABLE.
MASS
w 1659.
TOWN OF BARNSTABLE'
i t ,
Building Permit Application
Project Street Address STh E E-t i
Village '
�y14 NN�.r
Owner ZAn,,ar�cjub1e 1 nv,r Address Iy6 &SovrjN 'IrkJ tjyhmw)r
Telephone
Permit Request iLe iLyo P�Nc Ara . A+ s1
First Floor 7 C square feet Second Floor square feet
Construction Type cu o o•o
Estimated Project Cost $ �b"•o
Zoning District Flood Plain Water Protection
Lot Size . `d1 y Grandfathered ❑Yes ❑No
Dwelling Type: Single Family Two Family ❑ Multi-Family(#units)
Age of Existing Structure Historic House p Yes VNo 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
No.of Bedrooms: Existing 3 New
Total Room Count(not including baths): Existing S New First Floor Room Count
Heat Type and Fuel:-dGas ❑Oil ❑Electric ❑Other
Central Air ❑Yes 'ONo Fireplaces: Existing New Existing wood/coal stove ❑Yes No
Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size)
❑Attached(size) ❑Barn(size)
❑None ❑Shed(size)
❑Other(size)
rr
Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑
Commercial ❑Yes No If yes, site plan review#
Current Use Proposed Use JU r 1 ok.tj >C-A L_
99,, Builder Information
Name Z1'�►RA) NHnniS (�(n 1®yce Telephone Number '7 !
Address 1 9 t 1,,avrA R.dC_ License# 0 11 O 3 S
N*_w.rC t M A , y b Home Improvement Contractor#
Worker's Compensation# (u 10 3 p 'I.3 G�
NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN(AS BUILT)SHOWING EXISTING,AS WELL AS
PROPOSED STRUCTURES ON THE LOT.
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO b!j O-W•f ZN L
SIGNATURE .. ^-� DATE i 1 /i3 1 pl7 oti S' 1
BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S)
elp
Cell �' v
c
Ar FOR OFFICIAL USE ONLY ,
PERMIT NO. dt
a 1
DATE ISSUED
MAP/PARCEL NO.
ADDRESS d VILLAGE
OWNER '
DATE OF-INSPECTION: _ t 74 t r
FOUNDATION
FRAME
INSULATION
FIREPLACE•
.1c
ELECTRICAL: ROUGH FINAL t
PLUMBING: ROUGH 'FINAL
GAS: ROUGH FINAL_
FINAL'BUILDING
DATE CLOSED OUT
ASSOCIATION PLAN NO. t
9
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OG
�y THE
r The Town of Barnstable
Health Safety and Environmental Services
Department of
Building Division
367 Main Street,Hyannis MA 02601
Office: 508-790-6227 Ralph Crossen
Building Commissic:
Fax: 508-790-6230 _
For office use only
: '
Permit no-
Date
AFFMAVIT '
HOME IMPROVEMENT CONTRACTOR LAW
SUPPLEMENT TO PERMIT APPLICATION
MGL c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization,
conversion, improvement, removal, demolition, or construction of an addition to any pre-existing
owner occupied building containing at least one but not more than four dwelling units or to
structures which are adjacent to such residence or building be done by registered contractors, with
certain exceptions,along with other requirements.
Type of Work: rLo v t.Cost
Address of Work: 1 MA h1ymN JJ W -
Owner's Named mH c��� ➢��'''� "�
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
Work excluded by law
Job under S1,000.
Building not owner-occupied
_Owner pulling own permit
Notice is hereby given that:
OWN PERMIT OR DEALING WITH UNREGISTERED
OWNERS . PULLING THEIR
CONTRACTORS FOR APPLICABLE HOME IMPROVEMENNT OR MGLO 14ZA O NT RAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
SIGNED UNDER PENALTIES OF PERJURY
I hereby apply for a permit as the agent of the Owner.
i113 M �''��N
Iq &)OW�J-
Date Contractor Name Registration No-
OILk/ Q
w
T/rc• Cunu1ruirrt,ctrlt/r of.-Vastuchusctts
Deparlrncnt of Lttlustrial.4CCllIG'ttts
. �• ,� . . � OfficPa/IayesUgatlons
r•w
608 f 1'asltin tutr Street
Bi)stnir.A1usx 02111
`.
Workers' Compensation Insurance Atfitl:n•it
Plcnse 1'R11VT'lei �Iv"""'�'^'•�-M-'��^M _--- --�-IE Er -T.informatinn• _
namc•
IOc9tion-
rite• Philtre 8
I am a homeowner performing all wort:myself.
I am a sole proprietor and have no one working in any capacity
_-.... ...._._ ._—�-•---.__�.�,�.�.....��,•-�-,ate-�•-- .. .��..5.�_....._.r.�..,---•--_....
--e, I am an emplover providing workers' compensation for my ern pIovees working on this job.
eniminni• n•tmi• 13&.&A)rT19 pt C Noter%w�, A L�t1o+�tT\l
�tidrecc• ��6 FJOt�� �YYKlv7 Y -
v •
inc==rnncern IZ0 W•1✓ &.,DV'Q Vj`� nnlici•!t W1O a
I am a sole proprietor. general contractor, or homeowner(circle one) and have hired the contractors listed below Who ha.:
the tolloNving workers' compensation polices:
cnmrin w mine*
ltitirccc•
Ciro'• nhntlC&'
incnrnncc rn ^^loci'd
_-.•__._ .. _._ ._.�-_....._. -I_.�..��..--.. --ter����..,- -_ '•1• � - -
cmmninV n•trnc•
'idtlrccc• '
riti•• Phone#•
incurznce rn Policy d 7-77
Attach additional sheet if necessicv :."' ^_ .r _-�i•.•;v....r _.. .. .•...+...�......rr. v....°,:.. �:��'.'�`:y�ey •"�.w.;��.a.
F:ulurc to secure cm,crace as required under Section ZSA of 11IGL in can lead to the imposition of crtmtnal penalties of a line up to St.500.u0 andiur
one cars' impry onmcnt:ts weil as civil penalties in the form of a STOP WORK ORDER and a fide of S100.00 a day against me. I understand that n
Copy of this aatcinent nisi be forwarded to the office of invcstig2tions of the DIA for coverage verification.
I do herchi•ccrrift•tinder the plains and pettaittes of pciiuq that the information provided above is true mid correct.
Sianature R�y, I a- Date i /3 9
r Phone# ��1—��a�-
Print name �fLdC}.1� ► 1 �all,TA 1SU.A� -
w -
oRcial use unii• do not ii•rite in this area to be completed by city or town ofrtciai
city nr tniwn: permit/license 0 r•ttluildin".Department
CLiccnsing Board L
:3 chcci:if immediate response is revolted 0
Scicctmen's Ufficr t
�. �ttcalth Department �.
contact person: phone
i
information and Instructions
Massachusetts General Lmvs chapter 152 section 25 requires all employers to provide workers' ctrmpensatian for
employees. As quoted from the "fa►+". an empluree is defined as every person in the service of anotlier under any
contract of hire, express or implied. oral or written.
• -• individual. partnership. association. corporation or other legal entity. or ally 1%%-o or ir,
An c n�plut cr is defined as an m p P rn
the foregoing cnm_nged in a joint enterprise. and including the (esal representatives of a deceased employer. or tlu
recci+•er or trustee of an individual . partnership. association,or other legal entity, employing employees. Ho++,e%
owncr of a dwelling house haying not more than three apartments and who resides therein. or the occupant of the
d► ellin`g house of another+vlto employs persons to do maintenance ,construction or repair work on such d+vellin�g
or on the `_rounds or building appurtenant thereto shall not because of such employment be deemed to be an empio%
MGL chapter 152 section :5 also states that ever• state or local licensing agency shall withhold the issuance or
�01111l of a license or permit to operate a business or to construct buildings in the commonwealth far any
icarrt ►►•ho lins not produced acceptable evidence of compliance with the insurance coverage required.
Adc::1onall+•, neither the commonwealth nor any of its political subdivisions shall enter into any contract for the
performzt:ce of public work until acceptable evidence of compliance with the insurance requirements of this chactc-
been presented to the contracting authority.
,
Applicants
Please ril in the workers compensation affidavit completely, by checking the box that applies to your situation and
supplying company names. address and phone numbers as all affidavits may be submitted to the Department of
industrial ,Accidents for confirmation of insurance coverage. Also be sure to si gn and date the affidavit. The
iav it should be resumed to the cif} or town that the application for the permit or license is being requested.
r zhe Department of Industrial .Accidents. Should you have any questions regarding the "law" or if you are reeui-d
.o obtain a workers' compensation policy. please call the Department at the number listed below.
City or Towns
Plea-e 7e sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
the a"'davit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Nil
be _. _ to fill in flue permit license number which will be used as a reference number. The affidavits may be returnee
-'te Department by mail or FAX unless other arrangements have been made.
The Office of Inyesti nations would like to thank you in advance for you cooperation and should you have any questic
please do not hesitate to _give us a ca11.
The Department's address. telephone and fax number:
The Commonwealth Of Massachusetts
Department of Industrial Accidents A-41.-•
office at investigations
600 «'ashington Street
Boston,Ma. 02111
fax 1: (617) 727-7749
phone -. (6171 727-4900 e%r. 406. 409 or
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