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0091 MAPLE STREET
v �� > _ _ � - � \ Cape Save Inc. 7-D Huntington Avenue South Yarmouth, MA 02664 Tel: 508-398-0398 Fax: 508-398-0399 7/19/19 Brian Florence CBO Town of Barnstable Building Division BUILDING DEPT. 200 Main St. Hyannis,MA 02601 AUG '1 20t9 RE: Insulation Permit 19-1896 TOWN OF BARNSTABLE Dear Mr. Florence: This affidavit is to certify that all work completed for 91 Maple Street, Hyannis has been inspected by a third party Certified Building Performance Institute (BPI)Inspector. All work performed meets or exceeds Federal and State Requirements. Sincerely, William McCluskey Town of Barnstable Buildingt' Post This;Card So That�t�sUis�bleFrom:,theStre to roved Plans Mus#be;Re#arced on Job andthis Card Mus#3be;Kept IMAeLe x • •..ram r:,� " I� :i M" Posted UntilPermit BAR SFinallnspection Has Been Made ' R� �� s Where..a Certificate of Occupancyas�Requ�red;--such Buiidmg shall Not=be Occupied untit a Finat lnspect�on has been made �...�=: ,x, u.: ....' ...`�, :: .,�...�. 3Sa_- ...:....._ .s:.�..�..:,.,a :>.m�.�, .�,. ,-.:r':? .tee...,_.,:2"=.ss..�w.�''_ ,..,.<,t;: ::• ,.a"�a: ',; � .,� ..... .,a _"�,�. ct"k�. .;, Permit NO. B-19-1896 Applicant Name: William McCluskey Approvals Date Issued: 06/10/2019 Current Use: Structure Permit Type: Building Insulation-Residential Expiration Date: 12/10/2019 Foundation: Location: 91 MAPLE STREET,HYANNIS Map/Lot 310-370 Zoning District: RB Sheathing: Owner on Record: SAMEDY,JEAN E&TSYBULSKAYA; Contractor', ame �; WILLIAM J MCCLUSKEY Framing: 1 Address: 91 MAPLE STREET Contractor)Ucense CS -102776 2 HYANNIS, MA 02601410, Est Project Cost: $3,000.00 Chimney: Description: Add R-38 fiberglass, R-22 cellulose,and R-21 cellulose to the attic. ' PefmiCE0 : $85.00 Air seal the attic plane with expanding foam.General E ; Insulation: 85.00 weatherization. Date a 6/0/2019 Final: x Project Review Req: Plumbing/Gas Rough Plumbing: :w 5& Building Official Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within s6x months after issuance. All work authorized b this permit shall conform to the approved a licatio and the'a roved construction document rfor whicFi this permit has been ranted. Rough Gas: Y p pp pp F pp p g g 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 publicrospection 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 ar provided on this,permit. Minimum of Five Call Inspections Required for All Construction Work: , ' • Service: - 1.Foundation or Footing 1 ' 2.Sheathing Inspection $� ,- Rough: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: . 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 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). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT e-tlr�au�► /f �. Town of Barnstable REE'rPT HAM 200 Main Street, Hyannis MA 02601 508-862-4038 "9. Application for Building Permit Application No: TB-19-1896 . Date Recieved: 6/7/2019 Job Location: 91 MAPLE STREET,HYANNIS Permit For: Building-Insulation-Residential Contractor's Name: WILLIAM J MCCLUSKEY State Lic. No: CSSL-102776 Address: West Yarmouth, MA 02673 Applicant Phone: (508) 3 -0398 (Home)Owner's Name: SAMEDY,JEAN E&TSYBULSKAYA, Phone: (508)237-872 KATSIARYNA -s� (Home)Owner's Address: 91 MAPLE STREET, HYANNIS,MA 02601 C:) n Work Description: Add R-38 fiberglass,R-22 cellulose,and R-21 cellulose to the attic. Air seal the at.c plane with ending foam. General weatherization.. cm Total Value Of Work To Be Performed: $3,000.00 Structure Size: 0.00 -0.00 0.00 Width Depth Total Area I hereby swear and attest that I will require proof of.workers'compensation insurance for every contractor,subcontractor,or other worker before he/she engages in work on the above property in accordance with the Workers' Compensation Act(Chapter 568). I understand that pursuant to 31-275 C.G.S.,officers of a corporation and partners in a partnership may elect to be excluded from coverage by filing a waiver with the appropriate District Office;and that a sole proprietor of a business is not required to have coverage unless he files his intent to accept coverage. .I hereby certify that I am the owner of the property which is the subject of this application or the authorized agent of the property owner and have been authorized to make this application. I understand that when a permit is issued,it is a permit to proceed and grants no right to violate the Massachusetts State Building Code or any other code,ordinance or statute,regardless of what might be shown or omitted on the submitted plans and specifications. All information contained within is true and accurate to the best of my knowledge and belief. All permits approved are subject to inspections performed by a representative of this office. Requests for inspections must be made at least 24 hours in advance. Signed: William McCluskey 6/7/2019 (508)398-0398 -Applicant Date Telephone No. Estimated Construction Costs/Permit Fees Total Project Cost : $3,000.00 Date Paid Amount Paid Check#or CC# Pay Type Total Permit Fee: $85.00 6/7/2019 $35.00 lXXXX-XXXX-XXXX. Credit Card 0299 I Total Permit Fee Paid: $85.00 ....�.......__ ......� ..,. � __•. 6/7/2019 ' $50.00 XXXX-XXXX-XXXX- Credit Card 0299 Town of Barnstable i111lilg uPostMTh�s�Card So That rt�isVisible=From;the Street ,A_ roved�Plans Must�beoRetamed on Job and;this.Card Must be Kept •- BARNS[AB.tE, Permit jjjl• M'*� Posted UntdFFinal�lnspection���„„H,as�Been Matle =� � k b�� � � � � i R Wh�ee�a Gertificateof�Occu anc �i�Re, uired�;such Buldmgrshall NotYbe,Occupied until�Finallnspeetion�has been made � �� i �l t Permit NO. B-18-3153 Applicant Name: SAMEDY,JEAN E&TSYBULSKAYA, KATSIARYNA Approvals Date Issued: 10/03/2018 Current Use: Structure r Permit Type: Building-Alteration INTERIOR Work Only- Expiration Date: 04/03/2019 Foundation: Residential Map/Lot 310 370 Zoning District: RB Sheathing: Location: 91 MAPLE STREET,HYANNIS }Contractor=Name Framing: 1 Owner on Record: SAMEDY,JEAN E&TSYBULSKAYA, o�ntractor License 2 Address: 91 MAPLE STREET ' Est Project Cost: $ 10,000.00 Chimney : HYANNIS, MA 02601Perrnit-Fee: $101.00 Vnt f Insulation: Description: Second Bathroom in the right side in the baseme A Fee�Paids $101.00 Date 10/3/2018 Final: 771 Reviewers Note:Raised Ranch 3 Plumbing/Gas Project Review Req: Rough Plumbing: + Building Official iiA Final Plumbing: F Y Rough Gas: Final Gas: This permit shall be deemed abandoned and invalid unless the work authorzed by this permit,,is commenced,withm six months after issuance. Electrical All work authorized by this permit shall conform to the approved application and the approved construction documents-for which this permit has been granted. All construction,alterations and changes of use of any building and structures shall be in compliance with#the local zoning by la s and codes. Service: This permit shall be displayed in a location clearly visible from access street or road and shad Abe maintained ope for pubficAnspection for the entire duration of the Rough: work until the completion of the same.„ The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. Final: Minimum of Five Call Inspections Required for All Construction Work: Low Voltage Rough: 1.Foundation or Footing 2.Sheathing Inspection Low Voltage Final: 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 Health 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Final: 7.Final Inspection before Occupancy Fire Department Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Final: Work shall not proceed until the Inspector has approved the various stages of construction. "Persons cont unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Application Wwmm .....J.... ....... ..1.�✓.. . ......... * � ` Q�1 Permit Fee.......................................Other Fee........................ «I.' ; 'clC�-�� TotalFee Paid................. ....................... SEP 24 2018 TABLE PecmftApproval by.. ............. . . .on...... . TOWN-OF BA.RN�S� � ��' ... ..... ..... ..... ...._ BUILDING PERMIT �.--.�..._��...�.�............ParceL1..�...... ...�................:..: APPLICATION Section I —Owner's Information and Project Location Project Address I Village Owners Name Mr—D• / Owners Legal Address 5 l city. ��1'tN KI L state J ' �� zip (� owners Cell# '5'6' Ismail :F—h2L" Ss�L "fl�tlo0e CovI Section 2—Use of Structure Use Grroup ❑ Commercial Structure over 35,000 cubic feet ❑ Commercial Structure under 35,000 cubic feet Single/Two Family Dwelling Section 3—Type of Permit ❑ New Construction ❑ Move/Relocate ❑ Accessory Structure ❑ Change of use ❑ Demo/(entire structure) ❑ Finish Basement ❑ Family/Amnesty ❑ Fire Alarm Rebuild ❑ Deck Apartment ❑ Sprinkler System ❑ Addition ❑ Retaining wall ❑ Solar Renovation ❑ Pool ❑ Insulation Other—Specify Section 4 -Work Description _CQ _ T Acr :2/92019 ApplicationNumber.................................................... Section 5—Detail Cost of Proposed Construction Square Footage of Project �8 Age of Structure Dig Safe Number # Of Bedrooms Existing Total#Of Bedrooms(proposed) 110 MPH Wmd Zone Compliance Method ❑ MA Checklist ❑ WFCM Checklist ❑ Design Section 6—Project Specifics ❑ whing ❑ Oil Tank Storage ❑ Smoke Detectors Plumbing ❑ Gas .❑ Fire Suppression ❑ Heating System ❑ Masonry Chimney ❑Add/relocate bedroom Water Supply Public ❑ Private Sewage Disposal Municipal ❑ On Site Historic District Hyannis Historic District ❑ Old Kings Highway Debris Disposal Facility: I amusing a crane ❑ Yes ❑ No Section 7—Flood Zone . Flood Zone Designation Within or adjacent to a wetland, coastal bank? Yes ❑ No ❑ Section S—Zoning Information Zoning District Proposed Use Lot Area Sq.Ft. Total Frontage Percentage of Lot Coverage #of Dwelling Units (on site) Setbacks Front Yard Required Proposed Rear Yard Required Proposed Side Yard Required Proposed Has this property had relief from the Zoning Board in the past? ❑ Yes ❑ No r Last imdated:2/9=18 -------------- Application Number........................................... Section 9—.Construction Supervisor Name_ Telephone Number Address City State Zip License Number License Type Expiration Date Contractors Email Cell# I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your license. Signature Date Section-10—Home Improvement Contractor Name- l } Telephone Number Address City State Tap Registration Number Expiration Date I understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780 CMR the Massachusetts State Bolding Code. I understand the construction inspection procedm es,specific inspections and documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your H.LC... Signature Date Section 11—Home Owners License Exemption Home Owners Name: Telephone Number._ 0��`�'j� Cell or Work Number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT SIGNATURE Signature Date312-ylg, Print Nameb 71F,19 nl Telephone Number �° E-mail permit to: VYLIc _ S32,(-_,)_`(4 001 COWL T..4- •1/A/1A1 0 •L Section 12—Department Sign-Offs Health Department ® Zoning Board(if required) ❑ Historic District ❑ Site Plan Review(if required) ❑ Fire Department ❑ Conservation ❑ For commercial work,please take your plans directly to the fire department for approval. Section 13—Owner's Authorization I, , as Owner of the-subject property hereby authorize to act on my behalf in all matters relative to work authorized by this building permit application for: (Address of job) Signature of Owner date i Print Name • Last=dated:2/92418 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: 0 1 NDLU-' City/State/Zip: } D2-W Phone#: ��� _ Yee Are you an employer?Check the appropriate box: Type of project(required): L❑ I am a ❑employer with 4. I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 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 t 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.r 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. 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: 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#: �� — 84 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to 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 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 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 Roston,MA 02111 Tel.#617-727-4900 ext 446 or 1-877 MASSAFE Revised 4-24-07 Fax#617-727-7749 www.mass.gov/dia ') t - -•-.. ...._.......--------- (P- Barnstable Bldg. Dept. Approved by-... Am elL, Permit r p GJ/-- F- 7 Barnstable Bldg. Dept. Approved by: �A� Permit #: ����✓�f'�3 - - ��.._..r-�-_' ,� �`�r,fi �1� 7� U\Df�"' t �r�9 si-��i '�3' :'�^.'1�1..�'f r^�e ,;� ,.d( --- >. :.. Azi (PC8 . �1� i� o2b I Tp® � ZOI, Town of Barnstable *Permit 1 , Expires 6 m sue date Regulatory Services. Fee BAPJMABLE. MAM � % Thomas F.Geiler,Director 039• `0� ' Building Division Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma us Office: 508-862-4038 : Fax:.508-790-6230 EXPRESS PERAUT APPLICATION - RESIDENTIAL ONLY �''o �1/\ Not Valid without Red X--Press Imprint , Map/parcel Number 0 Pr p rly Address 9-A !tee st ylff,*15 G o f `' Residential Value of Work, Minimum fee of$35.00 for work under$6000.00 Owner's Name&Address_�� 4L S�R1/ITteoJ Contractor's Name_-� _524M,1� Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) �i❑Workman's Compensation Insurance Check one: ❑ I am a"sole proprietor c N-I am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must accompany each permit. Permit Request(check box) ❑ Re-roof(hurricane nailed)(stripping old shingles) All construction debris*will be taken to ❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof) Re side j� L #of doors ❑ Replacement Windows/doors/sliders.U-Value (maximum.35)#ofwindows ❑ Smoke/Carbon Monoxide detectors 4 floor plans marked with red S and inspections required. . Separate Electrical&Fire Permits required. *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sign Property Owner Letter of Permission. A copy of the Home Improvement Contractors License&Construction Supervisors.License is required. SIGNATURE: The Caxaotsynoffivea th of Massachusefts arfinent a,f fadusbiat-4 ccidenn Office of Invesfi'gations ' 660 Washington Street Boston,M4 62111 . rvrcnv�ri�tssvv/di a Workers' Compensation Insurance Affidavit BuiMerslCalmtractoi-JElec#ric ans/Ph mbers Aivptieant Information Please Print Leab N,aj�je 4Business0ganizatimffudividn o: r-) 2Q.t/ 341"a-I- Address:q—[ 04LeS ' ( Phone 4_ 0F -�- CityfStatefZip: Are you an employer? Check the appropriate box Type of project(required): 1.❑ I am a employer with 4 ❑ I am a general contractor and I 6- ❑New construction employees(full andlor part-6me)-* have d the sub-contractors prD er _ listed an the attached sheet ?- ❑Remodeling '�❑ I am a sole e�txri cyrp ship and have no employees These sub-contractors bate g- ❑Demolition w g, forme in a employees and have workers' �n j manramm I - ❑Building eEldit3aII o�'cam-insura=e comp. /} 3. ❑ We are a corporation asrd its 1 G.❑Electrical repAjYR Or additions J required] 1-1 - I am a homezwner doing all work officers have exercised their 11-0 Plumbing repairs or additions mys-6f [No workers'comp right of exemption per IwfGL 12.❑Rc of repairs insurance required.]T c. 152,§1(4),and we have no employees-[No workers' t13.❑0th0 � comp.insnrancae required.] 'Any appli'� s that checks box#1 unost also 5Il oat the section below sbasring their workers'ca mpeasatian policy infacrostiam- Y Homeowners who submit this of b vd 1mdIr3tM9 they are damg xH vnnt amd then hire outside contracmrs omit submit a new affidavit indicating surh ICa=,cmrs thst check this ben mast attached za addiiiansl sheet showing the nsme of the sub-cmftacbm and state whether or not those enrities have emphgies. Ifthe sd�contmcrws have employees,they—15tPm'id&dr aarkere comp.policy number- Iurn axis alanpi��arr tirrrtisprovidirrg.worir�ers't;oaaperesrrliorr ir�sarrria<ce for r'ra,�'arrzp�*es.� B�e�toty u tirRp�ic�arrid,jab sits informadam . Insurance Company Name: Policy-or.-self ins.Lie. Expiration Fate: Job Sites kd&ess: CityfStatelZip: Attach a copy of the workers'compensation policy dedaratioa page(showing the policy number and mgixation 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 S1500-00 an&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 whised that a copy of this sts# meat may be forwarded to the Office of Irves4gations of DIA for wsurmme anmrage veaffCaticn- ' 3 do horrib,y certa&aade r tkspauans anrdponah'&s ofpedW7 fJrat the informatka proidded abo"is bue nand correct Date , ; 4 Phone#: ©mad aw only: Der not write in this ova,to be cvan:pleteed by city or temi o WaL . C-Ityr ur'Town:. PerrmiitUcense# Issuing Authority(circle one): 1..Soar d.of Health2.Bual�Iirrg I}epattmeut 3.{ 4yll own Clerk' 4.Electrical Inspector .Phbin Inspector Phone#: - Town of Barnstable Regulatory Services * snarvsrwaXZ " Thomas F.Geiler,Director Mass. E1 59. Building Division Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 www.town.barnstable.m.a.us Office:. 508-862-403 8 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DA7E / JOB LOCATION: er street village "HOMEOWNER": =PJ1� n 1 ome phone work phone# CURRENT MAILING ADDRESS: i city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be, a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit. (Section 109.1.1) h The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws, rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and.requirements and that he/she will comply with said procedures and requirements. Sign ure 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. . • EVLM9ras[s 9� ,� Town of Barnstable .. . prEp Mp.l s Regulatory Services Thomas F.Geiler,Director. Building Division Thomas Perry,CBO Building Commissioner 200 Main-Street- Hyannis,MA 02601 www.town.barnstable.ma.us ' Office: 508-862-4038 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder as Owner of the subject"property hereby authorize to act on my behalf, in.all matters relative to work authorized by this building permit application for: (Address of Job) Signature of Owner Date Print Name If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on,the reverse side. QAWHILESTORWbuilding permit formslEXPRESS.doc Town of Barnstable �oFcwr rod Permit# 2 Erpires 6 moittlrs from issrte datr Regulatory oxy ,services Fe& S FtARVSTAB[I3, Thomas F. Geiler, Director ,,,, $ATE �a -PRESS PERMIT Building Division Toth Perry, CBO, Building Commissioner !\'OV 5 2011 200 Main Street, Hyannis, MA 02601 i www.town.barnstable.ma.us TrXA1N•OF BARNSTABLE Office: 508-8 62-403 8 Fax. 508-790-623 0 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY ivor Valid tPithorrt RedX-Press Inrprin! �✓" Map arcel Nuaber�16� - �� � . o Pr petty AddressM54ple- Cors , Residential Value of Work inimum fee ofS35.00 fox-work underS6000.00 Owner's Nam e Address Contractor's Name JG�-S OSG' IJU Telephone Numberl b; Home Improvement Contractor License#(if applicable) l rp g9� JAD X1,rrkCman's tion Supervisor's License#(if applicable)_ 7—oo7-2 - . Compensation Insurance Va one: m a sole proprietor m the Homeowner ave Worker's Compensation Insurance Insurance Company Name le-,,j ej_�l W bVorkman's Comp. Policy# (� _ S Copy of Insurance Comph:ance Certificate must accompany each permit. Permit Request (check box) ❑ Re-roof(hurricane nailed) (stripping old shingles) All construction debris will be taken to /Ropliacement urricane nailed)(not stripping. Going over existing layers of roof) rs Windows/doors/sliders. U-Value �e 3 #ofdindo (maximum .35)#of window *Where required: Issuance of this permit does not exempt compliance with other town de-partment regulations,i.e. Historic,Conservation,etc, ***Note: Property Owner must sign Property Owner Letter ofPermission. A copy of the Home Improvement Contractors License & Construction Su req ui pervisors License is NATURE: PFILESVFOPUVSIbuildingperniifoar7z EXPRESS.doc The Cornmonwealtli Department of Industrial Aeeideiits „J OffiC e of Investigations ' 600 Washington Street x 'y4; Boston, NIA 02111 t.4.r_ v.µ' '�1 wbl w.mass.gov1di<a Workers' Compensation Insurance Affidavit: Builder°s/Contractor-s/E lee tr°icians/Plumbers Applicant Information Please Print Legibly Name (Business/organization/Individual): v( � Address, } 5� r?s City/State/Zip: ((, T jT 1! 31 Phone M etc "65-? 5-/;?-D` Are you an employer?Check the appropriate b : TyVRemodeling ct(required): 1.U I am a employer with 4= 4. I am a general contractor and 1 6nstruction employees(full and/or part-time).' have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. 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.❑ 1 am a homeowner doing all work officers have exercised their 1 LE] Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ Other comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: .5 /Lc/ �—y"i" S CC) Policy#or Self-ins.Lic.M 06 1 6 6 Expiration Date: I - Job Site Address: 91 AukCity/State/Zip: /!/ C�/ 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 ains and penaltie erjury that the information provided above is true and correct. Si ature: Date: �'� ZL Phone#: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: i a ... �"�+1 'C✓lt!li:h=/9.s::�C.�.e%li �._.�Iar::✓t�.ar::�!•i,i �• LLO11//:��r��C��O11�pp��Ct�CC9Ot1`:'LC2�:g �f�aYir/sue/&t1�uRxiAaesa^Rreoutataioa 7 Registration:.'126893 Tyra: :s" Expiration, 43t*2 Suopie„me7t t The Nome Depol krf lome Services DARREN DEMERS.::.': " ' S 2690 CUMdERI.AND PA KVC AY S - 1�W%.GA 30339 • U-nderseeretarf License or registration valid for individul use only Wore the expiration date. If found return to: Office of Consumer Affrairs and Business Regul:,atioa 10 Park Plaza-Suite 3170 ;ard Boston,M. A.02116 Not valid without signature ® DATE(MMIDDIYYYY) ACCUR�Io► CERTIFICATE OF LIABILITY INSURANCE 02/21/2011 il.-��: 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 1-404-995-3000 CONTACT NAME: Marsh USA, Inc. PHONE FAX -(A/C.No.Ext)<---------- ----- AIC N, ----------.-.._.._..._... AIL homedepot.certrequestQmarsh.com ADDRESS: Two Alliance Center, 3560 Lenox Road, Suite 2400 Atlanta, INSURER(S)AFFORDI— C COVERAGE ------------_-—NAC#GA 30326G— ._I Fax (212) 948-0902 INSURER A: Steadfast Ins Co 26387 INSURED INSURERB: Zurich American Ins Co 16535 The Home Depot, Inc. Home Depot U.S.A., Inc. -INSURER C: New Hampshire Ins Co 2 384 1 2455 Paces Ferry Road NW INSURERD: Illinois Natl Ins Cc 23817_ Building C-20 NATIONAL UNION FIRE INS CO OF PITTS 19445 Atlanta, GA 30339 _ � INSURER E: INSURER F: Illinois Union Ins Cc 27960 COVERAGES CERTIFICATE NUMBER: 19834682 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. rA -ADDL SUBR - POLICY EFF POLICY EXP TYPE OF INSURANCE POLICY NUMBER MM/DDIYYYY MMIDDIYYYY LIMITS GENERAL LIABILITY GL04 887 714-01 .03/O1/1 03/01/12 EACH OCCURRENCE $ 9.,000,000 X DAMAGE TO RENTED 1,000,000 COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence $ CLAIMS-MADE �OCCUR M_E_D E_XP(Any one person) $EXCLUDED -.- - X LIMITS OF POLICY XS _ PERSONAL&ADV INJURY $9,000,000 X OF SIR: $lM PER OCC GENERAL AGGREGATE $ 9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 9,000,000 - X POLICY 7 PRO LOC $ JECT B AUTOMOBILE LIABILITY BAP 2938863-08 03 01 1 03/01/12 COMBINED SINGLE LIMIT 1000,000 Ea accident ------ -L- , ............._.-.. X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOSV AUTOS Per accident) X SIR AUTO P $ UMBRELLA LIAB HOCCUR EACH OCCURRENCE_ $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ C WORKERS COMPENSATION WC061967352 (AOS) 03/01/1 03/01/12 X O YLIMIT ER AND EMPLOYERS'LIABILITY D ANY PROPRIETOR/PARTNER/EXECUTIVE YIN NIA WC061967354 (FL) 03/01/1 03/01/12 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? N❑ E (Mandatory in NH) WC061967353 (CA) 03/01/1 03/01/12 E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under 1,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C Workers Compensation WC06 19 673 55(KY,MO,NY,WI, )03/01/1 03/01/12 F TX Employers XS Indemnity TNSC46244151 (TX) 03/01/1 03/01/12 Occurrence/SIR 30M/1M E Workers Compensation WC1192378 (QSI) 03/01/1 03/01/12 SIR 1M DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) ' RE: EVIDENCE OF COVERAGE CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE HOME DEPOT, INC. THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN HOME DEPOT U.S.A., INC. ACCORDANCE WITH THE POLICY PROVISIONS. 2455 PACES FERRY ROAD NW AUTHORIZED REPRESENTATIVE - BUILDING C-20 ATLANTA, GA 30339 USA ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD jfiero hd 19834682 The COMMonweolth of Massachusetts MA DeparfmOnt of IndUS&W Accidents Qfflce of Invesdgadons 9) 600 Washington Street Boston,MA 02111 www.massgov/dla Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers AiDaIjUnt Information Please Print Le 1 Name(Basinssiorganizz6owbdividus!)• 1!� Address: city/state/zip: /►'0 (J Phone#: Are you as employer?Check the appropriate box: l.T am s employer with 4• ❑ I am a general contractor and I Type ofPro t(required): mployees(Rill and/or part-time).• have hired the sub-contractorsconstruction 2. airs s sole proprietor or partner- listed on the attached sheet, 7. emodeling ship and have no employees Then sub-contractors have working for me in any capacity, employees and have workers' 8' ❑Demolition [No workers'comp. insurance comp.instuance3 9. ❑Building addition required:] 5. ❑ We arc a corporation and its 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their I LO Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL insurance required.] t c. 152,$1(4),and we have no 12❑Roof re pairs 3a.❑ I am a homeowner acting as a employees.[No workers' 13.0 Other general contractor(refer to#4) comp.insurance ] 0Any OPPltpot that checks box#1 mint Also till out the action below showing their worker'compeasatlod�oHey infbrantion.t Homeowom who submit this affidavit indicating they are doing all work and then biro outside cantracton must submit a new affidavit indicating such• tContnrctors that check this box must attached an additional sheet showing the same of the and state whether or not than entities have ernployeea. It the stub-cant ulf have employees,they mud provide their workers'comp,policy Madw. I an an em+rployer that It providing workers'compensation boarance for m y em"ployem Below rut Ike po&7 and fob site Insurance Company Name: Yepmk Policy#or Self-ins. Lic.#: 1J (� () Expiration Date: Job Site Address: ,1 / e �� City/StatdZip: Z:7;3rniM'flns Attach a copy of the worken'compensation policy declaration page(showing the poU no he ��Failure to secure covers as cy date). coverage required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to 31,500.00 and/or one-year imprisonment;as Weil as civil penalties in the form of a STOP WORK OR of up to$250.00 a day against the violator. Be advised that a copy of this and a fine statement may be forwarded to the Office a a Investigations of the DIA for insurance coverage verification. of I do hereby cerd j rur -s-,••jk d pen _ _ err 1h the lnformatiow provided show it Alai and corrnt -=-- 3i p Phone#: O,f'&fol use only Do not write in this area,to be complt*d by city or town offlClat City or Town: Permit/License# Issuing Authority(circle one): I.Board of Health L Building Department 3.City/Pown Clerk 4.El eetricalin Inspector ap r S.Plumbing Inspector Contact Person: Phone#: Infor mation and In S' tructions 4 g peal Caws chapeet 132 cegtsitea an empbyaae�1��s aaot contract olMra. punuad is thin shtnte,an goIidgve is defined as"...every Person expreaa of irgtllCd►oral or written." aft of UW two at morn As aWhpw is defined sa"as Wb i&4 p�P►usocia�co�aa'�i0n-dva o[�deceasad cuVW 'a�a for olfor Aerapiot� a joid eaterpdae.and iac � recaivet at bsabee o[d parim�M1 avoeiadon o><othat[epl eaelty,e�b>� E do ownat of a dwellb* ad moat♦the thine ePsaMMUS and w6n reeidar&W"or the o cctqpsdcttbs dweWe fi boost of aaMhet win"mpk"pawns to do co�dw oe R�wak on such dwellt bonne or an do pounds of b�didbg gees sban not bmm otmck eu fbym o be deemed es bo a•gmpby§Lle MPPwIewd MOL ch@PW 132;#23C(G)she swo dual"svaf Starr w 169d 3980bl apney Shan w"W"M tie t• s bwhi W is anet>rnd b�V toe es wwralek dr aq resewnl d a Ueenee K Psfmit °tea evidere d eemp9me with toe twrasar town np rogmkw appiltast won oar art Pa'aireei so "Nfidw the comm�oswealto vat aa>y of her politleal sabd�ab�s Addldoeaily.Mom.chaplet p hnne of do wait udn a agobb evidence otcomplLace with the Wwanes edet hale+4 to the�sadas WAR ay, � requkeema of dds cbapow p Apt the boxes the apply to�sieuaden anal,it Plum tlt out the worbaas' p1s a�tvit CO S' with that cerdAeata(a)at =y sotea(e)onaee(el~addteee(o)and phone asmbea(i)abs� other tuns the tnOMMM� Lwdwd ►Camped"(LL Q of Lisdad L.labitity PtaaaRshioe( ' °O�1o2'"e ruembaee arm an not tequired to errywarlOWingwe nr Iran L LC of L.lY doer havw ee*p60 a ponfin b" q °a tin ca"nvL W = bes fto dw alAdadt 'tie atLldavi!should Aeaidaer ibt 000 he the P�a lieeeee is be ft ngsealed eat the of be reltsse'd the dh ar town that the the taw os i[yon pan regsieed Oe obeaie a wabees' I da-POats � ham �♦heed below. SdEinMw oompaeiea shMM edit their coadpesadoa poifan ota..can the Dapaamaeet liner sdEiemaaoe hies'@ umber as the cur oe Taws OMMalr plane be on than the ditvit is=Mieft and Pbwd 10017- T w DVwwuw tins paorided a space at tun bod m o(the dodavil lbt M out is the cued the OtBn atbra dpdene has to Coded Yon nWWWR the plan be stare to 9111 Is the p ° whieo win be nned as a eetbreoa otaobea: [s addidoar,a•appdead that muee submit muldpie piss�p�00e is MY O•Ysss;°�01°h'�os a®davit iodhadon aaareat polirey td wbW ar U460 V aaey)end usdw-lob SM AAkwe the appllead should write"an t adwe tn__,jcity of tmrs}»Aeon dthn afA it�bee ben ofikledy swe"d or�by do cq or teS may be paovided tr thr uppacod r pwdtmt a valid affidavit to on Ble Air ilseea�e paamitr a Ilaasaea. A new atLWsvit muetbe dl>6ed out each �.wbae a bom owbet of chinas is obteidao s licence at permit ad mhW M any burr or commai1' ve�e i.e.a dog limns at psmth to boss leaven eee.)said Pena YOri're-is OW es c"V'W idle afil"L rw Offin ol invadpdow would lilts Is thank Yon is adv=*ON your cooperation sad should yoo hm my 4uadw4 please de are bodo e M SW as a caLL LjgNwwWe t@kPb m and At:mtaabett Thtt Co mmoovtrertitli of Mat�chusatb - - Depr>�ment of fndu Md Aai&nls Of fa of law"Ods" 600 WaAb&G Sorter Bosim MA 02111 Tai. 11 6 1 7-121-4900 ext 406 of I.Vl'NfA99AFE Fu a 617•J27-1749 Revised 11.22416 ",moLVv/d)s Qfffifice of Consumer Affairs and Ifusiness Regulation 10 Park Piazu'- Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration - '- Registfation: 132349 ;~ Type: PaM 1fersh 3r$ 2Q7382 Remodeling Joseph Duarte 15 Fall St. - Wareham, ma 02571 Update Address and return card.Mark reason for eia Cd n Address 0 0 Rmpioymtat ❑IA* •8.0A1 p SOM-004-0101210 License orKregistration valid fas s�ividnl aae saw 0OlBce before the eXpi tdm date. If ft"d r9sn to: HOME lMpR0VEMFgT CONTRACTOR oltiee of Consumer Affairs sad Business Regut dw Registration: 132349 10 Park Plaza-Suitt 5170 Expiration: 301/2013 partnership Boston,MA 02116 jamnodeling: ` ` • .;t: _ Joseph Duarte ` 15 Fall St. �... �.- 0257 idretit of art UdrreeretryWareham,ma VIVI %j::AChuwtts.Dcparuarnt of puhlic vakfe '1 Board Of 8uitdim:Rt'"V1atiun.anti stun+t:trti� Construction supervisor License License: Cs 70071 JOSEPH C_DUARTE 15 FALL ST WAREHAK AAA 02571 Earn: 112 Trl{: 700 (..nmdwmKar Z94696Z . 116ZlZ0/10 t0 39CId Nov 14 11 04: 11p Michael. .Bedard 1-.401-246-2868 p. 1 HOME IMPROVE1tIEIVT CONTRACT PLEAW READT11IS SoK Furnklied and Installed by; , Branch Name: Boston Date: TIlV At-Home Servims.Inc. d/h/1"The Holne Depot Ar-Ifonw Services 3-45A Greenwood Strut,Unit 2,Worcester,MA 01607 Toll Free(800)657-5182;Fax(50H)756-8823 Breach Nuatlrer, i1 Federal ID 975-2698460-tclr Lac#C 112439;RI Coat.t.ici}16427 C'.TLic Of HiCR%. ')522;MA Homo improvement Co/nectar Reg.a 126893 Inslallatinu Address:. _q... - t'>! _ C,.ity slate Zip l'ur hacer(s): Work phone: Rome Phone: Cell Phone: home Address: (irdi.Mrent from ln5tailatirm Address) City Stine Zip E,muil Address fto wceive project cornrnunications raid Hume;Depot updates): _ ❑1 DO NOT wish to receive cony r aurketing elnaiLs from The Ifouu:Depot Protect Informatio i Undersigned f"C'uidtbtocr'".),the nwnerx of the property located at the above installation address,agrees to buy. end'I'H_At-Home Services.Inc,("The Htune Depot")agrees to furnish,deliver and arrange for the installation("in:ttrillation")of P5 all mult:rial5 described on the below and on the referenced Spa~Sheet(s),all of which am iucorporatat into thiv Contract by this reference.,along with any applicable State Supplcrnent and payment Sutwcary anaehed hcrculo and any Change Orders(collectively, "C)nntrnet"): J<>L#: tax sew netr:+nc1 m1ucL: Spec Shect(ai 9: Project Amount —Q Rnnfin[ Siding Windows ❑it w(mica Q! ! Qtiutterc I C.:vvcts F]Nntry�tuus ❑ Y as f7 6 _ 1II 2 Il nn[]�9rtg Sldine. ❑Windows Q tnitrirtian __ ( j�Gutters!Covets ©hnay Acwrl 0 _ - $ i QRordi.n,'. Siding.❑R'indows ❑iostJ;uinn $ QGuttcrs I Cvccrs ❑tuuy Dolts❑ _ -- Kvnrvi❑ R ❑Sidin ❑Windowsg Insu ulion � I S I QGoutcrs l Covers Qrntry i)oars ❑_ diinimtun Z5r;6 1)efiteitofContract Amount due uponesecutina of th6eiintram Total Contract Antouat $ Maine PhrrtlnagnntaynnLikliusitmomthaunonitthirdof the CtinuadAn�unt. rjt � r Customer agrees thn immediately upon completion of the work Air t.ich Produel,Customer will execute a Completion Crnilicate (one for i:uch Product a.dt:lined by an individual Spec Sheet)and pay any balance due. As applicable,ench Cust a ter under this Contract agrees to be jointly and severally ohligated and liable hereunder. The Ilona Depot reserves the right to issue a Chahgc Order or terminate this 0intrtct or any individual Product(s)included herein.at iti discretion,il'Tot:Homo Depot or its authari7ed service provider determines that it cannut perform il,obligations due to a structural problem with the honte,environmental hazards such as mold.ashestot of lead paint,other safety conccrnS,pricing cxrocs or)-:cause work required to complete the job was not included in the Colitracl. Payment Summary; Thu Payment Summitry#L33�6 V_�L _, included as pafl of this Ctal(rtrot ,,els forth the total Corltrict;maottnt and puyment,�required for tiic•.tlepncits and final payments by Product.(as apphcahlej. N'OTICIC TO CUSTOMFIR - You are entitled to:a completely filled-ila COPY Of the COnlraet at the time You sign. Do do(sign a Completion Certificate(note: there is one Completion Certifrcale liar eneh listed Produel av defined by individual Spec iheets)before work on that PrndutK ih complete. In the event of termination of this Contract,C;ustenter agees to pay Tllc Nome Depot the east,;of trinterialy,labor,e%pcnses and scr0ceg provided by The I1Ame 1)cpol or Authorized Service Provider through the dale of lerniblation,plus any other amounts set forth in this Agreement or allowed under applicable law. THE HOME,DET('1'MAY WIVU101,1)AMOUNTS OWED TO THE: HOME pu:POT VROM THE UPPOSIT PAVAENT OR (YI'HLR PAYh1EN'I'S MADE, WiTHOUT LIMITING THE HOME AF.PtYF'S OTHF:(t R1�1E DIES r0W REC'OVVRY OFSUCH AMOUNTS. Aeeuulanc�nnd-Authorization: C1lstonrxr agrees and utlderstunds Thal this Agreement is the entire atgrcemettt between Cusma>i and The Ronnie d)eput with fegard to the Products and Installation services and Aupersedes all prior diseumitms and agmenletus-either oral or written,relating to Said Pntulucts and inwallition.This Agn cment Cannot he as ilmed,or amended except by a wriring signed by Customer and-The!ionic Depot.Custoitlet acknowledges and agAecs that Customer has read,understands,voluntarily accepts the tLrm.s of and has received at Lupy of •.Agreement. _ Su -tted bY: v ior's Signarp. 4 v •• Date J Salem onsuftanC•X Sr nalure Date/ Telephone No l� � b 5 ('uwumer'sSidmatutti .. "' llure Sale%Consultant Ilerea:No. _ C-ANCE11,I.ATION: CUSTOMIRR.MAY CANCKi, TRIS (:ual41FIcable.) AGREEMENT WITHOUT PFNAL'fV OR OBLIGATION BY DELIVERING IYRITTF.N:NOTICi?TO THE HOME DE14yr BY mimicirr ON THIC THIRD RUS1NTeM DAY A17P.R SIGNiNG 'PHIS AGREEMENT. THE S1'ATF. SVPPLTh1KNT A17TACMED i ERTTU C(ATAINS A I(OR14i TO UiR IT, ONE IS SPEMC:ALLY PRESC'RIRED- BY LAW IN CUSTOMER'S STATE. NIMC M AIMITIONAL TUMS AND CONnrr[ONS ARF.',STATF;n ON THK ALVPXSE SiUt.A VD ARP PARTOF Tftls'r.V. NTRACT 12.27-10 CSG n u n - L/L d. Spy 10d0d awoH << 1U`?L56805 3NOHd'KUML92 L020 W_LL_Mz Engineering Dept. (3rd floor) Map N%0 Parcel Permit# House# g j d` `� Date Issued Board'of H )(8:15 -9:30/1:00-4:30) Fee ��Sf Conse - e 7oor)(8:30-9:30/1:00:2:00) Planniu. .. gw hool Admin. Bldg.) �,NE De 'gtreet Planning Board 19BARNSTABLE. F° TOWN OF BARNSTABLEBuilding Permit Application Address y/ JYI. e ST, Village_ llgg lv , Owner X 7, c _ ewe, G V Address S Z15r Telephone #y3O Permit Request if If b®F 1- Jvs?w�� ti '3 �t�'%�' leoo 13 First Floor square feet Second Floor square feet Construction Type Estimated Project Cost $ i7jv,ad Zoning District Flood Plain Water Protection Lot Size Grandfathered ❑Yes ❑No Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House ❑Yes ❑No On Old King's Highway ❑Yes ❑No Basement Type: ❑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 New Total Room Count(not including baths): Existing New First Floor Room Count Heat Type and Fuel: ❑Gas ❑Oil ❑Electric ❑Other Central Air ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove ❑Yes ❑No Garage: ❑Detached(size) Other Detached Structures: ❑Pool(size) ❑Attached(size) ❑Barn(size) ❑None ❑Shed(size) ❑Other(size) 'Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes ❑No If yes, site plan review# Current Use Proposed Use Builder Information Name '01 e-, 0A t*4,P,0 Telephone Number 6`b 7,90 Of4r Address ;5'( i32 `k L4, License# 0 O `!'17,— hc.r(1,&"11. 164,, 09-6 6/ - Home Improvement Contractor# l M'�6 9 Worker's Compensation# 7/'-'- yC4—/9n6l6a-74S 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 SIGNATURE DATE- —? — BUILDING PERMIT dNIED FOR THE FOLLOWING REASON(S) FOR OFFICIAL USE ONLY PERMIT NO. r 1 4 DATE'ISSUED: MAP/PARCEL•NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. °F VE r °: The Town of Barnstable KAM �axsrea� -: &639. � Department of Health Safety and Environmental Services �rFDMA'�a Building Division 367 Main Street,Hyannis MA 02601 Office: 508-790-6227 Ralph Crossen Fax: 508-790-6230 Building Commissioner For office use only Permit no. Date AFFIDAVIT HOME IMPROVEMENT CONTRACTOR LAW : SUPPLEMENT TO PERMIT APPLICATION MGL;c. 142A requires that the "reconstruction, alterations, renovation, repair, modernization, conversion, improvement, removal, demolition, or construction of an addition to any pre-existing owner occupied building containing at least one but not more than four dwelling units or to structures which are adjacent to such residence or building be done by registered contractors, with certain exceptions,along with other requirements. Type of Work: ,7T•�/!� �e �� Est.Cost 7 aae,00 Address of Work: Owner's Name 7"�✓��� JJ � �� Date of Permit Application: /��9,60 Ir I hereby certify that: Registration is not required for the following reason(s): Work excluded by law Job under$1,000. Building not owner-occupied Owner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 142A SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner: Date dontractor Name Registration No. OR Date Owner's Name The Commonwealth of.Massachusetts ;i;;�` • Department of Industrial.4ccide�rts A OWCOOf111=t/yat/ons 600 11'ashinrton Street Boston, Mass. 03111 Workers' Compensation Insurance Affida-s•it _ �pniic —n nformation 'ocntion' � sits phone 0 I am a homeowner performing all wort:myself. I am a sole proprietor and have'no one working in any capacity t w...w....y.,//•.�.�..r..�..��q.A•r�+.y.fwRr[1.."��/.�.�a�`_-...:: - - - ...� � �••. n•.wn.�..�� 1 am an employer providing workers' compensation for my employees working on this job. compnm•name• atitirecs• city nhone i!• 7 g6 incurnnce co I am a sole proprietor. general contractor, or homeowner(circle one) and have hired the contractors listed below wile the following workers' compensation polices: comn•tm• name, -- - ddres cih nhone�• incurince ro cnm nm• name* 'tddre c• city nhone ft• iasur•tncc co _ _ noiic�•s'! .Attach additional sheet if riecess "::r _+.t"v "� f "'''a'•' -• '•.Ir.•_n+ +�,,,,��, -"�"' '' ~y Failure to secure coverage as required under Section 25A of NIGL 152 can lead to the imposition of criminal penalties of a fine up to S1.500.UU an one years' imprisonment as well as civil Penalties in the form of a STOP WORK ORDER and a fine of S100.00 a day against me. 1 understand it. copy of this statement may be forwarded to the OMce of Investigations of the DIA for coverage verification. t do herchv certifj•under 1/tc pains and penalties of pedurt•Ilia'file information provided above is true and correct Signature: 5, �G `�C Date Print me _ � Sr , ��t/P'lf�f� Phone 0 na got Iiciai use univ do not write in this area to be completed by city or town official - city or town: permit/license# mlluilding Department C3Ucensing Board 13 check if immediate response is required E3seieetmen's Office C]ticaith Department contact person: phone#• mother- Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for emplovccs. As quoted loom the "law". an empinree is defined as every person in the service of another under an: contract of hire, express or implied, oral or written. An enrplurer is defined as an individual, partnership, association. corporation or other legal entity. or an%, two or the foregoing enuaged 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. Howev, owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the d%%!cllin`,, house of another who employs persons to do maintenance , construction or repair work on such dwellin; or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an emp: MG chapter i522 sect' ion 25 also states that every state or local licensing agency sliall witliltuld the issuance o renewal of a license or permit to operate a business or to construct buildings in the commotim-ealth for any applicant ,%vilo lras 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 Nvork until acceptable evidence of compliance with the insurance requirements of this chap been presented to the contracting authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to ;your situation z 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 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 re--- to obtain a workers' compensation police, please call the Department at the number listed belo„-. Cin• or Tomms Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottc the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. be sure to fill in the permit/license number which will be used as a reference number. The at may be retur.- the Department by mail or FAX unless other arrangements have been made. The Office of Investigations would like to thank you in advance for you cooperation and should you have any que: 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 3 to €QNtAC ` v ATO L `°»►moo ft EtZ601 511A