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0257 MITCHELL'S WAY
��� �/ ir G �-- -�, _ -o- f -- � � i i�_, REGISTRATION,AND CERTIFICATION FORM FOR FORECLOSING/FORECLOSED PROPERTY Thank you for registering in accordance with Town of Barnstable Code chapter 224 sections 224-3 and 224-4. Please complete one form for each property in foreclosure (section 224-3) or already foreclosed for which possession has been taken(section 224- 4). Please file the original with the Building Commissioner and a copy with the Chief of the Fire District in which the property is located. If you claim you are exempt from registering under Massachusetts law,pleases ate the reason(s) and complete section 1 (property information) and the first par agraphof section 2 (foreclosing party, court, etc. and foreclosing party representative, bdt�not othez Dow representatives and attorney) so that the Town can review the exemption and update its �, z records: cao A ao w M w Section I —Property Information Property Address:257 Mitchell's Way, Hyannis MA 02601 Assessors Map#: 290 Parcel #: 108 Land area and description building is located on .32 acres Building(s) description and contents 3 bedroom, 2 bathroom 1,276 sq ft. built in 1959. Occupied: Occupant(s)(if borrowers so state and include name(s)) Phone: email: other: Vacant: X Date: Unknown Anticipated Length of Vacancy: Unknown Last occupant(s) )(if borrowers so state and include name(s)) Phone: email: other: Has_possession been-taken If so, please explain and complete and file the maintenance and security plan form (unless exempt as stated above) Section 2—Foreclosing Party Information Foreclosing Party (full name/title) Foreclosure Case Court: Docket# Date filed: Current Status: Foreclosing Party's representative(s) for property (entry, management, repair, etc.)(name,title,): • Company (if different from foreclosing party): US Bank Trust NA Trustee LSF10 Master 13801 Wireless Way, OKC, OK 73134 C/O CAliber Homes Loans LLC Address: Phone: 602.-842-1013 email: other: I udson.pre)erv�tion@northsight.com If an exemption is claimed,please o not complete t e remainder. Other representative(s) (if foregoing representative is primarily responsible for property and/or foreclosure and is most likely to be able to address town matters concerning the property and/or foreclosure,please so state and do not complete contact information (i. e. "none" or"see above")). Name, title, other: Company (if different from foreclosing party): Northsight.Management Address: 8901 E Mountain View Rd Suite 100, Scottsdale AZ 85258 Phone(s):602-842-1013 email(s):hudson.preservation@nootnesight.com Name, title, other: 1-800-516-1553 24 Hrs Company (if different from foreclosing party): Address: Phone: email: other: Attorney representing foreclosing party Firm name (if different from attorney's name): Address: Phone(s): email(s):- other: I acknowledge that the information provided is accurate and correct. I also understand that any inaccurate information will result in non-compliance with section 224-3 of chapter 224 of the Code of the Town of Barnstable. Date: 9/11/2019 Na e: ve Johnson - POA attached Title: Agent for Owner r I hereby certify that the above-named foreclosing party is in compliance with the provisions of section 224-3 of chapter 224 of the Code of the Town of Barnstable: Date: Building Commissioner, Town of Barnstable LIMITED POWER OF.ATTORNEY Hudson Homes Management LLC, a company organized under the.laws of the State of Texas ("Hudson Homes"), as the manager of certain real property(the "Real Estate Owned"), 'hereby makes, constitutes and appoints Northsight Management Solutions LLC ("Northsight"),having its principal office located at 8901 E. Mountain View Rd. Suite 100., Scottsdale, AZ 85258, its true and lawful attorney-in.-fact with the power and authority, as fully as Hudson:Homes might.or could do;to sign; execute, acknowledge, deliver, or file instruments.on its:behalf for. the limited purpose of effectuating,:the registration of Real Estate Owned with municipalities, counties, 'states, and other governinent entities as.required by law, including the execution of documents; forms, and:other instruments necessary to;:comply with such law, when requested by Hudson Homes in writing containing reference to specific Real Estate Owned. Hudson Homes grants this Limited Power of Attorney to Northsight under the Mdster:'Property Services Agreement by.and between Hudson Homes.and Northsight executed.on September 10: 20'18 and as modified,and is subject to the indemnification provisions therein, Third parties without actual notice may rely upon the exercise of the power granted under.this:Limited Power of Attorney, and may be satisfied that this Limited Power of Attorney shall continue:in full force and effect has not been revoked unless an.instrument of revocation has been made in writing by the undersigned. This Limited Power of Attorney expires on the earlier of(i)'receipt by Northsight of revocation from. Hudson Homes or(ii)December 31.,2020. Rod Wylie;!:Senior' ice President STATE OF COUNTY OF �' 5 On this J day of IJA rf 2019, before me°the undersigned, Notary. Public of said State, personally appeared L� , personally known tome to be a'duly authorized officer of the entity that executed the.within:rnstrument and-personallyknown tome to be the person:who:executed the within-instrument on behalf of the entity therein named,and acknowledged to me such entity.executed the within instrument pursuant to its by-laws: WITNESS my hand and official seal, EVELYN WAIIHAKA a° a� Noiary Pubpc,Sttate of Texas; Comm.ExpUes Ot•07.2020. Notary ID 124251619 Notary Public in and for the State of WO#204854235 NO FEE REGISTRATION AND CERTIFICATION FORM FOR FORECLOSING/FORECLOSED PROPERTY Thank you for registering in accordance with Town of Barnstable Code chapter 224 sections 224-3 and 224-4. Please complete one form for each property in foreclosure (section 224-3) or already foreclosed for which possession has been taken(section 224- 4). Please file the original with the Building Commissioner and a copy with the Chief of the Fire District in which the property is located. If you claim you are exempt from registering under Massachusetts law,please state the reason(s) and complete section 1 (property information) and the first paragraph of section 2 (foreclosing parry, court, etc. and foreclosing party representative,but not other representatives and attorney) so that the Town can review the exemption and update its records: Section 1 —Proj2eLty Information Property Address: 257 MITCH ELLS WAY,HYANNIS, MA 02601 Assessors Map#: HYANM:2901-:108 Parcel#: HYANM:290L:108 Land area and description N/A Building(s) description and contents 1 STORY;SINGLE FAMILY; RESIDENTIAL Occupied: Occupant(s)(if borrowers so state and include name(s)) Phone: email: other: w ' rrVacant XX 1Date: 01/04/19 Anticipated Length of Vacancy: UNKNOWN CA _ . ast occu ant(s))(if borrowers so state and include name(s)) - o--CORREIR ,GEORGE&SUZANNE oG None: email: n/a other: n/a o ca flas posse n been taken Yes If so, please explain and complete and file the intenan rand security plan form(unless exempt as stated above) Section 2—Foreclosing Party Information Foreclosing Party (full name/title) CALIBER HOME LOANS, INC. Foreclosure Case Court: Unknown Docket# Unknown I WO#204854235 NO FEE Date filed: 11/01/16 Current Status: CLOSED-PROP IS REO Foreclosing Party's representative(s) for property (entry, management, repair, etc.)(name, title,): Company(if different from foreclosing party): SAFEGUARD PROPERTIES Address: 7887 SAFEGUARD CIR,VALLEY VIEW,OH 44125 co�ecompliance@safeguardproperties. om Phone: 800-852-8306 eman: otcher: If an exemption is claimed,please do not complete the remainder. Other representative(s) (if foregoing representative is primarily responsible for property and/or foreclosure and is most likely to be able to address town matters concerning the property and/or foreclosure,please so state and do not complete contact information (i. e. "none" or"see above")). Name, title, other: MAIZA ELOY-BROKER Company(if different from foreclosing party): Address: 1533 FALMOUTH RD,CENTERVILLE, MA 02632 Phone(s): 508-568-8202 email(s):meloy@todayrealestate.com' other: Name,title, other: n/a Company (if different from foreclosing party): N/A Address: Phone: email: other: Attorney representing foreclosing party N/A Firm name (if different from attorney's name): n/a Address: n/a Phone(s): n/a email(s): n/a other: n/a I acknowledge that the information provided is accurate and correct. I also understand that any inaccurate information will result in non-compliance with section 2.24-3 of chapter 224 of the Code of the Town of Barnstable. Date: 01/22/19 Name: Safeguard Properties Title: Property Preservation I WO#204854235 ;r NO FEE I hereby certify that the above-named foreclosing party is in compliance with the provisions of section 224-3 of chapter 224 of the Code of the Town of Barnstable. Date: Building Commissioner, Town of Barnstable WO#204854235 NO FEE MAINTENANCE AND SECURITY PLAN FORM FOR FORECLOSING/FORECLOSED PROPERTY Town of Barnstable General Ordinances; Code section 224-4, requires a mortgagee taking possession of a property before or during foreclosure, or after foreclosure if the mortgagee becomes the owner, to bring the property into compliance with the maintenance and security standards contained in Code subsection 224-4(B)within thirty (30) days of a notice from the Building Commissioner. Please either complete and file this form or another containing the same information with the Building Commissioner' within thirty (30) days of the notice. If a mortgagee claims an exemption from the provisions of Code sections 224-3 and 224- 4, please explain, leave the remainder blank, sign at the end and file this form or letter of explanation and also complete and file the applicable sections of the registration form for foreclosing/foreclosed property 257 M ITCH ELLS WAY, HYANNI5, MA 02601 (1) Registration date: 01/09/19 If not registered, please complete the registration form and state date of filing or anticipated filing (2) If commercial property, describe space utilization floor plans required by the Fire Chief and filing date (actual or anticipated) N/A (if in possession or ownership must be certified as accurate twice annually in January and July). (3) Describe any hazardous materials on the property as that term is defined in MGL c.21K and the date(s)and method(s)for removal as approved by the Fire Chief N/A (4)Method(s) and date(s) all windows and door openings secured(or will be secured) 11/02/18 If left secured, name, address, and contact information of security personnel providing twenty-four-hour on-site security personnel on the property (5)Location(s) and date(s) "No Trespassing" signs posted or to be posted on the property N/A (6)Name(s), address(es) and contact information of person(s)responsible for. maintaining: structures, lawns and shrubs in sound condition free from excessive growth and the property generally in accordance with the Barnstable Zoning Ordinances the definition of"maintenance" in this Ordinance; any other provision of this Ordinance; and for disposing of trash, debris and pools of stagnant water as provided in Chapter 54 of the Town of Barnstable General Ordinances SAFEGUARD PROPERTIES;7887 Safeguard Cir,Valley View,OH 44125 800-852-8306;codecompliance@safeguardproperties.com WO#204854235 (7)If the Fire Chief of the Fire District in which the property is located has approved turning off the water or electricity, please state: Date of approval Date(s) electricity turned off on if applicable ; Date(s)water turned off on if applicable (8)Name(s), address(es) and contact information pf person(s)responsible for maintaining all existing fences around swimming pools and spas or installing fences as required by Chapter 210 of the Town of Barnstable General Ordinances SAFEGUARD PROPERTIES; 7887 Safeguard Cir,Valley View,OH 44125;800-852-8306;codecompliance@safeguardproperties.com (9)Name, address, telephone number and email address of person who can be contacted in case of emergency if different from the person named above or in the registration under section 224-3(A) (name and contact number to be posted on the front of the property if required by the Fire Chief or Building Commissioner (10) Date(s) certificate of liability insurance on the property filed with the Building Commissioner Unknown (11) Date(s) cash or surety bond of at least$10,000.00 filed with Building Commissioner to remunerate the Town for any expenses incurred in inspecting, securing and making the premises comply and continue to comply, a portion of which shall be retained by the Town as an administrative fee N/A (12) Date(s) scheduled for inspections with the Building Commissioner and Health Director, who may at his or her discretion include the Fire Chief, in order to confirm that the land and structures comply with the provisions of this Ordinance or to identify the provisions with which the property does not comply and establish a program to bring the property into full compliance (13) Date(s) when the property was sold, or is anticipated to be sold, to the foreclosing party. If neither,please-explain 11/02/18 I acknowledge that the information provided is accurate and correct. I also understand that any inaccurate information will result in non-compliance with section 224-3 of chapter 224 of the Code of the Town of Barnstable. �11j� Date: 01/22/19 Name: Safeguard Properties Title: Property Preservation Co. to Receive Violation Notices ` WO#204854235 I hereby certify that the above-named foreclosing party is in compliance with the provisions of section 224-4 of chapter 224 of the Code of the Town of Barnstable. Date: Building Commissioner, Town of Barnstable Anderson, Robin From: Deese, Tammy <tammy.deese@suez.com> Sent: Thursday, April 18, 2019 11:36 AM To: Anderson, Robin Subject: HYANNIS WATER RECENT SHUT OFFS 25 SKATING RINK RD SHUT OFF DATE 2/20/19 76 KELLEY RD SHUT OFF DATE 2/13/19f� � 175 BUCKWOOD SHUT OFF DATE 11/20/18 - �C�► L/+ Z57MITCHELL'S WAY SHUT OFF DATE 11/20/18 T 657 YARMOUTH RD SHUT OFF DATE 2/26/19 ** 62 BAXTER RD WAS TURNED BACK ON DUE TO CLAIMS OF 80 YEARS OF AGE AND BED RIDDEN FEMALE HOWEVER SERVICE TECHS NOTICE SEVERAL YOUNGER FAMILY MEMBERS AT-THE ADDRESS SEVERAL TIMES .WE ARE ALSO IN - RECEIPT OF A LETTER STATING THIS PROPERTY WAS SOLD AT AUCTION. SO AT THIS TIME THINGS AREA LITTLE.FUZZY WITH THIS PROPERTY. ALSO SPOKE WITH HANS REGARDING OUR CONVERSION YESTERDAY. HE ADVISED'ME GOING FORWARD TO EMAIL ALL APROVED SHUT OFF ADDRESSES IN ORDER TO KEEP YOU IN THE KNOW. THANKS FOR YOUR HELP , TAMMY DEESE COLLECTIONS CLERK 508-775-0063 X3516 . Before printing a copy of this email,please consider.the environment. This email and any attachments are confidential and intended for the named recipient or entity to which it is addressed only. If you are not the intended recipient, you are hereby notified that any.review, re-transmission, or.conversion to.hard copy, copying, circulation or other use of this message and any attachments is strictly prohibited. Whilst all,efforts are made to safeguard their content, emails are not secure and SUEZ cannot guarantee that attachments are virus free or compatible with your systems and does not accept,liability in respect of viruses or computer problems experienced. SUEZ reserves the right to monitor all email communications through its internal and external networks CAUTION:This email originated from outside of the Town of Barnstable! Do not click links, open attachments or-reply, unless you recognize;the sender's email address and know the content.is safe! . 10710 a �� � i - _ .. }� _ .. � � � ,' r v _ I:i k 1 _ .. - � � � - _ .' 1 _ _ _ 41�. P_I li. ;!+ '_, ,_ S �� ,,, � , �, �, �: �, — . f e;� 1 ,._ �, 4 - __ i J i, _ - .. _ �;. �� � +t I ... � i{ . - � ' i - � 4� ' _ �L� ' _ �JJJ .. - - � � � � �� +�I 1 1HE tiTOWN OF. BARNSTABLE Building Application Ref: 200801652 • * BRN ASTABLE, + Issue Date: . 07/18/08 Permit . 9 MASS �A 1639• �� Applicant: CORREIRO,GEORGE&SUZANNE Permit Number: B 20081496 Proposed Use: SINGLE FAMILY HOME Expiration Date: 01/15/09 Location 257 MITCHELL'S WAY Zoning District RB Permit Type: DECK/PORCH RESIDENTIAL Map Parcel 290108 Permit Fee$ 30.00 Contractor PROPERTY OWNER Village HYANNIS App Fee$ 50.00 License Num Est Construction Cost$ 1,500 Remarks APPROVED PLANS MUST BE RETAINED ON JOB AND CONSTRUCT A NEW 5X14 FRONT PORCH THIS CARD MUST BE KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN MADE. WHERE A CERTIFICATE OF OCCUPANCY IS REQUIRED,SUCH Owner on Record: CORREIRO,GEORGE az SUZANNE BUILDING SHALL NOT BE OCCUPIED UNTIL A FINAL Address: 257 MITCHELLS WAY INSPECTIU AH`�S B MADE. HYANNIS,MA 02601 Application Entered by: PR Budding Permit Issued By: THIS PERMIT CONVEYS`NO RIGHT TO OCCUPY ANY STREET;ALLY OR SIDEWALK OR AN!Y PART/THE EOF,EITHER TEMPORARILY OR.PERMANENTLY. ENCROACHEMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUIILDING C©�DE, ST BE APPROVED BYTHE JURISDICTION. STREETOR ALLY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY E�EROM THE DEPARTMENT OF PUBLIC WORKS THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FRO r T '+ CONDITIONS OFANY APPLICABLE SUBDIVISION RESTRICTIONS I MINIMUM OF FOUR CALL INSPECTIONS REQUIRED FOR ALL CONTS RUGTTON WOR 1.FOUNDATION.OR FOOTINGS. 2.ALL FIREPLACES MUST BE INSPECTED AT THE'F ROA LEVEL BEF �'E FIRS FLUE LINING IS INSTALLED. 3.WIRING&PLUMBING INSPECTIONS TO BE COMPLETED P IOR TO FR 1�vI INSPECTION. 4.PRIOR TO COVERING STRUCTURAL MEMBERS(READY PTO TH). 5.INSULATION. 6.FINAL INSPECTION BEFORE OCCUPANCY. WHERE APPLICABLE,SEPARATE PERMITS ARE RE IRED FOR �ECTRICAL,PLUMBING AND MECHANICAL INSTALLATIONS. WORK SHALL NOT PROCEED UNTIL JE INSPECTOR, AS APPROVED THE VARIOUS STAGES OF CONSTRUCTION. PERMIT WILL BECOME NULL AND VOID IF GeNSTRUCTION WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE PERMIT IS ISSUED AS NOTED ABOM PERSONS CONTRACTING W ISTERED CONTRACTORS DO NOT HAVE ACCESS TO GUARANTY FUND(as set forth in MGL c.I42A). BUILDING IN EC.ON APPROU�kLS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 1 1 1 2 2 2 3 1 Heating Inspection Approvals Engineering Dept Fire Dept 2 Board of Health TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Parcel Application# Health Division Conservation Division Permit# ��,, Tax Collector Date Issued 00 Treasurer Application Fe` Planning Dept. Permit'Fee /?i® Date Definitive;Plan Approved b Planning Board Historic-OKH u Preservation/Hyannis { Project Street Address ZS 7 M 1 T� -}�LL� L�/A-� j Village J 14;y�-N U Owner r=o C-->k® Address J�'7 m t rnjj '1.4.6 0111 TelephoneDe . g/3® 34/ Permit Request ro e; Square feet: 1st floor:existing 15p0 151P proposed 2nd floor:existing proposed Total new '—a " Zoning District Flood Plain Groundwater Overlay Project Valuation' 1- bo . Construction Type Panc-4 Lot Size Grandfathered: ❑Yes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure f 7 `/ Historic House: ❑Yes moo` �`On Old King's Highway: ❑Yes ®1 Basement Type: ❑ Full Qo'rawl & alkout ❑Other Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) 3 4a Number of Baths: Full:existing new Half:existing new Number of Bedrooms: existing 3 new Total Room Count(not including baths):existing new First Floor Room Count Heat Type and Fuel: 21 as ❑Oil ❑Electric ❑Other Central Air: Mo es ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes 91,110 Detached garage:❑existing ❑new size Pool:❑existing ❑new size Barn:O existing ❑new size Attached garage:❑existing ❑new size Shed: existing ❑new size 0- Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes 2 o If yes, site.plan review# Current Use Proposed Use BUILDER INFORMATION Name,-4—�Qene Telephone Number8 �1 ►3�l�/ 'Address c2-5-7 A4 17"e--A 126 License# pis 114-1 (44L-0 IY, -2 J Home Improvement Contractor# Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TOAf�/lJv13� i�l,� C tP- �c�v yy►ih!"Th Vrwi P SIGNATURE DATEANA* 31301,01 r r0 i FOR OFFICIAL USE ONLY y PERMIT NO. DATE ISSUED i MAP/PARCEL NO. • I r ADDRESS, VILLAGE ` OWNER' 'I j € DATE OF INSPECTION: FOUNDATION FRAME S INSULATION 3 r FIREPLACE ELECTRICAL: ROUGH FINAL _F a PLUMBING: ROUGH FINAL r - GAS: ROUGH FINAL FINAL BUILDING DATE CLOSED OUT ASSOCIATION PLAN NO. k ' The Commonwealth-of Massachusetts ( , Z Department of Industrial Accidents.' Office of Investigations 600 Washington Street - ' 1.- Boston, AM 02111 �y www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): GE'0t;,G6 Address: a-S /'iGI-4-EL46 WAq City/State/Zip: � n)A M / Phone#: 6Dt 7Z0 V7&l 5V8' 913 &V lq Are you an employer?Check the appropriate box: _ Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the'sub-contractors 2,❑ I am a sole proprietor or partner- listed on the attached sheet. $ �• Remodeling T ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. i workers'comp;insurance. 9. ❑Building addition [No workers' comp.insurance 5. ❑ We are a corporation and its equired,] � officers have exercised their 10.❑Electrical repairs or additions 3.(� I am a homeowner doing all work,, right of exemption per MGL 11.❑Plumbing repairs or additions . myself. [No workers' comp, c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.]t employees. [No workers' 13.[�ther P® 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 their workers'comp,policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site information. Insurance Company Name: Policy#or Self-ins.Lic.M Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a . fine 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 cert�o der the pains an 9pAalties of perjury that the information provided above is true and correct Si ature: Date: Phone#: 6b8�71,0-F-2 F, 3A3,6 Of 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The.Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,Mai 02111 Tel. 617-727-4900.ext 406 or 1-8,77-MAS E Fax.# 617-727-7749 Revised 5-2&05 wwwma.ss.gov/dia ,_��'� ��, a I�t UtZCZ1C s•►J E �C ttc c y e t flflfl 'f d T � 1 L L o 6F , f OISTE� �► 77 CLLS y K�Os )\4 A . Cx- Pv . III Al R �2�P�SE� Y oti��-� �-! �i���c III FC) �,4 "t L.rn� N L- 2X GI 2-T to"houRED C0wC.Sctitrq—( L)3 65 'j"13.(-,Low GRAbE Mt" jaLWGEs I J i-1�NtxCt� SF 14,=1 o T �� '• �INC l U1�1f1 WoUD I_ � 3 � �i ►�u-nsrE�2s 4c, S?ACE �Aj� �lElc�Nl 'l- z"< 36 FLASH A6111ALS NovSc f R CIZi AT %El.ow G(L-UE 3� GIaI,V. '3o�.TS 2xly YTII , � II l -E a� Ca i4c So N p TU Be E F (cW e- -ice P6j ' s 6 (I ea �� Q who oIZ �o ST S `I T So N� TO 3 E iM`n or�� �- .. '� .A�� �.. .���T�2 � � �— e , �" _ °' �-- .,�=- �---� ,-- s e s. � , o 0 �/� - �x �f ��s ���a �t Town of Barnstable Regulatory Services snantszABU& Thomas F.Geiler,Director 16 9. .�' Building Division ArE p s 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: �✓ / m l 7—�CE%(ilj4q number street ` village < g "HOMEOWNER": P�G� �Z �2fJ�"�� name dig erew# ugwi Pifflm#/74714c.� CURRENT MAILING ADDRESS: c ��rInI's /`L4+ city/to 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 l09.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes,bylaws,rules and regulations. The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department Fe .pection rocedures and requirements and that he/she will comply with said procedures and Signs re 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:\WPFILES\FORMS\homeexempt.DOC Town of Barnstable &UMSTABLE, MAW039. Regulatory Services ArEO �s 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 Q:\WPHLESTORMS\building permit forms\EXPRESS.doc Revise020108 Town of Barnstable Regulatory Services Thomas F.Geiler,Director �* Building Division sniwsr"14 9 KAM g Tom Perry,Building Commissioner �'°tEc �sum 200 Main.Street, Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 Approved: Fee: Permit#: HOME OCCUPATION REGISTRATION Date: Name: CjepVv,= C0YL'RC'. Im Phone#: SbS ?91) Address: y�5 7 m y T"c e LL,5 w 4 Village: VJM1y V)'s Name of Business: C Cen R UG l 1 p�J Type of Business• bO L LAe✓/ «do— 77-m Pn.r2 ap/Lot• INTENT: It is the intent of this section to allow the residents of the Town of Barnstable to operate a home occupation within single family dwellings,subject to the provisions of Section 4-1.4 of the Zoning ordinance,provided that the activity shall not be discernible from outside the dwelling. there shall be no increase in noise or odor;no visual alteration to the premises which would suggest anything other than a residential use;no increase in traffic above normal residential volumes; and no increase in air or groundwater pollution. After registration with the Building Inspector,a customary home occupation shall be permitted as of right subject to the following conditions: • The activity is carried on by the permanent resident of a single family residential dwelling unit,located within that dwelling unit. • Such use occupies no-more-than 400-square feet of space. - • There are no external alterations to the dwelling which are not customary in residential buildings,and there is no outside evidence of such use. • No traffic will be generated in excess of normal residential volumes. • The use does not involve the production of offensive noise,vibration,smoke,dust or other particular matter, odors,electrical disturbance,heat,glare,humidity or other objectionable effects. • There is no storage or use of toxic or hazardous materials,or flammable or explosive materials,in excess of normal household quantities. • Any need for parking generated by.such use shall be met on the same lot containing the Customary Home Occupation,and not within the required front yard. • There is no exterior storage cr display of materials or equipment. • There is no commercial vehicles related to the Customary Home Occupation,other than one van or one pickup truck not to exceed one ton capacity,and one trailer not to exceed 20 feet in length and not to exceed 4 tires,parked on the same lot containing the Customary Home Occupation. • No sign shall be displayed indicating the Customary Home Occupation. • If the Customary Home Occupation is listed or advertised as a business,the street address shall not be included. • No persons all be employed in the Customary Home Occupation who is not a permanent resident of the dwellinguW I,the undersigned=read agree with e a ove restrictions for my home occupation I. am registering. plicant Date• d ��81�p Homeoc.doc Rev.5130103 YOU WISH TO.OPEN A BUSINESS? For Your Information: Business certificates(cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town(which you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1"FL.,367 Main Street,Hyannis,MA 02601 (Town Hall) DATE: Fill in please: APPLICANT'S YOUR NAME: G-c, Cc>r rieLrzb BUSINESS YOUR HOME ADORES a�5't ✓vt tTG{�p L.15 3'CYa• 8L3-3ceL4 �y_a„nVi,Lb a-nU-�sS TELEPHONE # Home Telephone Number T08 `79 co -87ALf NAME OF NEW BUSINESS '}' TRUC 1b TYPE Q BI�I.SINESS �Y� IS TH1S.A DOME OCCUPA1101�1I. N0- Have ydu been give in approval frwran.the .building.dirtision?. YES NO . _YA y AppR SR t)F SUS11V[ SS -�4m tTC E L: cu MAP/PA tC1rL N.UIVIBI�R y' 1 When starting a'new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth Rd.&Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town. 1. BUILDING COMI 0NER'S OFFICE This in.dividu I h s er�inf of any permit requirements that pertain to this type of business. Aut orized nature* 16 COMMENT i 2. BOARD OF HEALTH. This individual has been informed of the permit requirements that pertain to this type of business. Authorized Signature** COMMENTS: 3. CONSUMER AFFAIRS(LICENSING AUTHORITY) This individual has been informed of the licensing requirements that pertain to this type of business. Authorized Signature* COMMENTS: Town of Barnstable *Permit d4(IQ4� Expires 6 months from issue date X-PRESS PERMIT Regulatory Services Fee CP,5 00 2006 Thomas F.Geller,Director JUN 1._2 Building Division TOWN OF BARNSTABLE Tom Perry,CBO, Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESIDENTIAL ONLY Not Valid without Red X-Press Imprint . Map/parcel Number o?9 6 Property Address vZ 5 ! 011-r�.tLS U 4,j A-n 1 S g2l(esidential Value of Work / Zzz Minimum fee of$25.00 for work under$6000.00 Owner's Name&Address Gbvet YI lit�n��c��.l�Lb CstJt9-�a ,�ArN1�1 .5 Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor g I- the Homeowner r ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to AAm W&NO ❑Re-roof(not stripping. Going over existing layers of roof) e-side r t7h► Est A t.�� �E�G�.Q-� peoeL �15#AC 912e, ❑ Replacement Windows. U-Value (maximum.44) *Where required: Issuance s permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: rop rty Owner must sign Property Owner Letter of Permission. e Impr ement Contractors License is required. SIGNATURE: Q:Forms:expmtrg Revise071405 Department oflndustrialAccidents I� Office of Investigations 600 Washington Street ' Boston,MA 02111 WWW massgov/dia' Workers' Compensation Insurance Affidavit:Builders/Contractors/Eleetridans/Plun hers Applicant Information Please Print Leldbly Name (Businesslorganization&&vidu4: G OO-4Gr C&rz�� Address: a-� City/Statosip: • Phone#: 6i . St3 3�.�c� Are you an employer? Check the-appropriate boa; Type of project•(required): 1,❑ I am a employer with 4. ❑ I am a general contractor and I 6• ❑New construction employees (fall and/or part time)*- have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet$ 7. ( Remodeling ahip and have no employees These sub-contractors bane & Demolition working for me in any capa,city.. workers' comp.insurance. 9. ❑ Building addition [No woken'Gump.insurance 5. ❑ We are a corporation and its required,] officers have exercised their 10,❑ Mectricalrepaus or additions 3. I am a homeowner doing all work right of exemption per MGL 1 l•❑ Pbm bing repairs or additions ruyself.[No workers' comp. c. 152,§1(4),and we have no 12 Roof r insurance required.]t , to ces. ❑ �� emp y [No workers' 13,❑ 06ier cam insurance, required.] *Any spplicaat that checks box#1 maet also fill out the section below ahowing their workers'compen"tion policyiaformatioa t$omeownan wbo submit this affidavit indicating they are doing all work aadthen hire outside contractors mmst submit anew aMdse indicating ouch. 1r, tracwn that check 1Ms boa must attached an additional sheet showing the acme of the sub-contractors and their waikae eonp•policy information. ram an employer that Is providing workers'compensation insurance for.my employees. Below is the policy and J'ob site Information. IasnranCd CompanyName• Folioy;or Bey-im Luc.Tr. Job Site Address. City/5ta&Mp. Attach a copy of the workers' compensation perky declaratton page(showing the policy number and W.lraUon date). Failure to secure-coverage as required under Section 25A of MGL c. 15.2esi lead to$ie imposition of criminal penalties �f a fine up to$1,500.00 and/or one-year imprisomnant,as well as civiil 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 eerti under the pains and penalties of perjury that the information provided above is true and correct. Si tore: Date le 1 6l� Phone# ' . 813 • 3( a,ff cia:AS6 . Da E M Ins sea,to be cmWefti-4.ct,or tnm eJJ125, City or Town: PermitUtense# I Issuing Authority (circle one); I 1.Bo2rd of health 2-Building IDepartment 3.City/Town Clerk 4.Electrical inspector 5,Plumbing iaspe&tar- 16.(Dtlier Coeact Person: Phone#: ' t } TOWN OF BARNSTABLE , CERTIFICATE OF OCCUPANCY 18-X 22- FMLY ADD W/DECK EXTENSION PARCEL ID 290 108 CEOBASE ID 19768 ADDRESS 257 MITCHELL'S WAY PHONE HYANNIS ZIP - 1 LOT BLOCK LOT SIZE DBA DEVELOPMENT ' DISTRICT HY PERMIT 88853 DESCRIPTION C/0 FAM RM ADD 18'X 22' PERMIT TYPE BC00 TITLE CERTIFICATE OF OCCUPANCY CONTRACTORS: Department Of ARCHITECTS: h Regulatory Services TOTAL FEES: BOND $.00 THE T CONSTRUCTION COSTS $_00 �%1• I 756 CERTIFICATE OF OCCUPANCY 1 PRIVATE 1OI1 __ * BARNSTABLK MASS. 1639. FD MA'S BUILDI t "IVISION BY (� DATE ISSUED 12/06/2005 EXPIRATION DATE TOWN OF B,ARNSTABLE BUILDING PERMIT .,� -► PARCEL ID 290 1.73 6EO.BASE ID 10' 768 ADDRESS 257 M,.TCHELL'S WAY PHONE HYANNIS ZIP - LOT BLOCK LOT SIZE DBA DEVELOPMENT DISTRICT HY PERMIT DESCRIPTION ADD FAM R.M. 18 X 22 EXTEND DECK 3' PERMIT TYPE BADDI TITLE BUILDING PERMIT ADDITION CONTRACTORS: BA%ARIAN KEVIN Department of ARCHITECTS: Regulatory Services TOTAL FEES: BOND $.00 CONSTRUCTJON COSTS $38,016.00 434 RESID ADD/ALT/CONV 1 PRIVATE 11'0'� + BARNSTABLE, + � MASS. i634. C/O FD a BUILDING DIVISION BY / r /� i-/ 4 —DATE ISSUED 02/15/2005 EXPIRATION DATE rt,% "CSC TOWN OF BARNSTABLE a BUILDING PERMIT PARCEL ID 290 108 GEOBASE ID 19768 ADDRESS 257 MITCHELL'S WAY PHONE . HYANNIS ZIP LOT . BLOCK LOT SIZE DBA DEVELOPMENT DISTRICT. HY PERMIT 82254 DESCRIPTION ADD YAM RM. 18 X. 22 EXTEND DECK 3; PERMIT. TYPE BADDI TITLE BUILDING PERMIT ADDITION CONTRACTORS; BAZARIAN KEVIN Department of ARCHITECTS: ,.Regulatory Services TOTAL FEES $2 35.87 BOND $.00 p�F CONSTRUCfIOW COSTS $38,016.00 434 RESID ADD/ALT/CONY 1 PRIVATE Im*;0 J.._.. +► BARNSPABLE, �►ss. 1639- Ae�. 'I BUILDING DEVISION BY DATE ISSUED 02/15/2005 EXPIRATION .DATE C/ THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET,ALLEY OR SIDEWALK OR ANY PART THEREOF, EITHER.TEMPORARILY OR PERMANENTLY.ENS CROACHMENTS ON PUBLIC PROPERTY,NOT SPECIFICALLY PERMITTED UNDER THE BUILDING CODE,MUST BE APPROVED BY THE JURISDICTION.STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROMTHE DEPARTMENT OF PUBLIC:WORKS.THE ISSUANCE OF.THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS OF ANY APPLICABLE SUBDIVISION RESTRICTIONS. MINIMUM OF FOUR CALL INSPECTIONS REQUIRED FOR ALL CONSTRUCTION WORK: APPROVED PLANS MUST BE RETAINED ON JOB AND WHERE APPLICABLE, SEPARATE 1.FOUNDATIONS OR FOOTINGS THIS CARD`KEPT'POSTED UNTIL FINAL INSPECTION PERMITS ARE REQUIRED FOR 2. PRIOR TO COVERING STRUCTURAL.MEMBERS HAS BEEN MADE.WHERE A CERTIFICATE OF OCCU- ELECTRICAL,PLUMBING AND MECH- (READY TO LATH). PANCY IS REQUIRED,SUCH BUILDING SHALL NOT-BE ANICAL INSTALLATIONS. 3.INSULATION. OCCUPIED UNTIL FINAL INSPECTION HAS BEEN MADE. 4.FINAL INSPECTION BEFORE OCCUPANCY. e ® ® s BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS 1 �©� ©Cc q-r Jg �- ��-2-7-0s 3 1 HEATING INSPECTION APPROVALS ENGINEERING DEPARTMENT. 2 BOARD OF HEALTH I OTHER: SITE PLAN REVIEW APPROVAL I WORK SHALL NOT PROCEED UNTIL PERMIT WILL BECOME NULL AND VOID IF CON- INSPECTIONS INDICATED ON THIS THE INSPECTOR HAS APPROVED THE STRUCTION WORK IS NOT STARTED WITHIN SIX CARD CAN BE ARRANGED FOR BY VARIOUS STAGES OF CONSTRUC- MONTHS OF DATE THE PERMIT IS ISSUED AS TELEPHONE OR WRITTEN NOTIFICA- TION. NOTED ABOVE. TION. I M I ix - TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 2A Parcel /Z�2 Permit# 6 a S Health Division _� Date Issued /S Conservation Division "0 `0/ * /� �' Application Fee Tax Collector 4AT J � Permit Fee , � Treasurer - - Planning Dept. Date Definitive Plan Approved by Planning Board umm=00MROM Historic-OKH Preservation/Hyannis Project Street Address 2 -7 VIn %T c,H E L L_S W `� Village _�—� LAC, A✓\x S Owner A r-1 v L. Co,r v-e t r--O Address f<a o r e L A vl, C rt. Telephone 13— 5" — v ( 1 `� ,-�U S'C �xa 7-7 p Yb Permit Request l `3 x Z2 Ebb 7' 1-) Ex1STI(46; Square feet: 1 st floor: existing proposed 3 1 2nd floor: existing proposed -- Total new 3 1 Zoning District Flood Plain Groundwater Overlay Project Valuation / O v O Construction Type W b0d, -pra w,W', Lot Size m 3 Z Grandfathered:)NOes ❑No If yes, attach supporting documentation. Dwelling Type: Single Family Two Family ❑ Multi-Family(#units) Age of Existing Structure Historic House: ❑Yes On Old King's Highway: ❑Yes No Basement Type: ❑ Full >g rawl ❑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 3 new Total Room Count(not including baths): existing �� new First Floor Room Count Heat Type and Fuel: Was ❑Oil Cl Electric ❑Other Central Air: ❑Yes �tslo Fireplaces: Existing A-/0 New rle S Existing wood/coal stove: ❑Yes N�V_No Detached garage: ❑existing ❑new size Pool: ❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:)S�existing ❑new size c�K� ZOther: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes o If yes,site plan review# Current Use S �jG m 0�1 ��Sc vt�; Proposed Use 11 r BUILDER INFORMATION ,4 Name � Telephone Number Address W License# 0 S ,!�7 ,6 Ll Home Improvement Contractor# / /1 2-7 ( Worker's Compensation# ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO D a l SIGNATURE DATEe T FOR OFFICIAL USE ONLY lv t RMIT NO. DATE ISSUED MAP/PARCEL NO. 4 �•' ' ADDRESS VILLAGE OWNER DATE OF INSPECTION: mac, � 16 f FOUNDATIONS FRAME INSULATION RXWS GC-- h' FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL--,% u GAS: ROUGH FINAL E FINAL BUILDINGo"', - DATE CLOSED OUT 920 ',r ASSOCIATION PLAN NO. ' r - ` '_ The Commonwealth of Massachusetts OEM Department of Industrial Accidents' 600 Washington Street Boston,Mass. .02111 Workers' Corm ensation'Insurance davit-General Businesses • row+.• .r�. ,�"'� �. .+ „ „ - aaa Co address: City. W WA 0 state: V " ZiD. �Zc� Rhone# .�` u `'���� work site location(full address): ❑ I am a sole proprietor and have no one Business Type: ❑Retail❑RestaurantBaAatih g Establishment " working in any capacity. ❑Office Q Sales(including Real Estate,Autos etc.) ❑I am an emplover with em to ees full& art time ❑Other %%/%////O%/ %/////////, /%% %//////%/%//%%%%%%/O/////////G%�%%�%%%%% I am an' providing workers' compensation for my employees working on this job.. comnariy•names. :i: '`•'' City' phone. 5 .insurarice.co I am a sole proprietor and have hired the independent contractors listed below who have the following workers' ; .compensation polices: company'a""anze= '`.G T`l ✓"•''V�'1} ld 1� 1V• �•� ``�1 '' .:; t ,'• 4. ..�v address• :�.�.,.•,. ';� t•`••'y-:••.' : � " phone'# : .J �':•• Z.S•'�:.. r.":...'.•' .. .• y ,fr•' }:.. insurance co. -.�< � ��' •s` :a. "a 'sa;i'e�} - -comb any n ; clty� :'pnotie# ' insuranceio:��• '-'''••`"''• 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$100.00 a day against me. I understand that$L copy of this statement maybe forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby c u the ' s a allies of perjury that the information provided above ' 'ue a orrect Sigaa Date G-r t f P �qa. Print name Phone# official use only do not mite in this area to be completed by city or town official city or town: permidlicense# []Building Department ` _ ❑Licensing Board ❑check if immediate response is required ❑Selectmen's Office []Health Department , contact person: phone#; ❑Other ' (mused Sept 2003) I Information 'and Instructions Massachusetts General Laws.chapter�152 section 25.requires all employers to provide workers' compensation for their.. from the law an employee' is.defined as every person in the semvice'of another under any contract to ees: As noted � . � Y q of hue, e implied, oral or written. express or unP . An em to er is defined as an individual,partnership, association, corporation or other legal entity, or any two or more of P Y the foregoing engaged in ajoint enterprise, and including the legal.iepresentatives 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 budding appurtenant thereto shall not because of such,employment.be deemed to bean employer. .. : . :. MGL chapter 152 section 25 also'states that every. state'or local licensing agency.shall ivithhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the.cdmrnonwealth for any applicant who has not produced acceptable evidence'of�co'nipliance with the insurance coverage required: Additionally, neither the connnonwealth nor.any.of its political subdivisions shall enter into any contract for the performance of public work unto acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting . authority. Applicants Please fill in .the workers' compensation 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 Departaient•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 Deparment 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. City or Towns . 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 perrri0cens.e number.which will b�e used as a reference number. The,affidavits maybe;returned to the Department by mail or FAX umiless other'arrangements have been made. 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 NO of waStlpa wns 600 Washington Street Boston,Ma. 02111 fax#: (617) 727-7749 phone#: (617) 727-4900 ext.406 o�VIE!,wy Town of Barnstable Regulatory Services 13 szoLs, Thomas F.Geller,Director Mass. 9`b i65 - Building Division 'Den MPt a g Tom Perry,Building Commissioner 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 . Fax: 508-790-6230 Permit no. Date AFFIDAVIT HOME IMPROVEMMNT 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 adj aceut to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. �J q ©�o 0 ou 111- 1 U "� Estimated Cost Type of Work: !id w�-� tM 1 � Address of Work: Owner's Name:, ��w�✓ Date of Application: 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 PROGRA A OR GUARANTY FUND UNDERMGL c.142A. SIGNED UNDER PENALTIES OF PERJURY P I hereby apply for a permit as the agent of the owner: III Z-7 Date Contractor Name Registration No. OR Date Owner's Name Q*nns:homeaffidav f RESIDENTIAL BUILDING PERMIT FEES APPLICATION FEE , ' New Buildings $100.00 Residential Addition $50.00 5 d ^a d Alterations/Renovations $50.00 Building Permit Amendment $25.00 FEE VALUE WORKSHEET. NEW LIVING SPACE�G C square feet k$96/sq.foot= �; B / 6 x.0041= ` . 7 plus from below if applicable) ALTERATIONS/RENOVATIONS OF EXISTING SPACE _square feet x$641sq.foot= - x.0041= plus frombelow(if applicable) - GARAGES(attached&detached) square feet x$321sq.ft.= x.0041= ACCESSORY STRUCTURE>120.sq.ft. >120 sf-500 sf $35.00 >500 sf-750 sf 50.00 >750 sf-1000 sf 75.00 >1000 sf- 1500 sf 100.00 >1500 sf-Same as new building permit: square feet x$96/sq.foot= x.0041- r STAND ALONE PERMITS Open Porch x$30.00= (number) Deck x$30.00 (number) Fireplace/Chimney x$25.00= ' (number) Inground SNAmnung Pool $60.00 Above Ground Swimming Pool S25.00. Relocation/Moving $150.00 (plus above if applicable) Permit Fee Projcost Rev:063004 no CMR Appmdis J Table JS=b(condoned) Prescriptive paages for Doe and Two-Family ResideotW Buildings Heated with Fossil Fuel ck MAXIMUM MINIMUM 'Wall Floor Basemeat 9teb 'Heariag/Cooling Glazing Glaring Ceiling :ter Equipment EMclenc? Area'(%) U-value= R-valuer R-value° R-value? R-wa ` perimeter package 5701 to 6500 Heating Degree Days Normal 12/a 0.40 38 13 19 10 6 Q ° 6 Nom msl R 12°/a 0.52 30 19 19 10 b 85�E g 12% 0.50 38 13 19 10 N/A— ----Normal 38 13 25 NIA --—--6----------- _.-Normal-.- ...------- -------.._ U '15% 0.46 38 19 19 10 N/A SS AFUE y 15% 0.44 38 13 25 N/A 6 85 AFUE W 15% 0.52 30 19 19 10 rm N/A Noal X 19% 0.32 38 13 2S NIA 1V/A Normal y 18% 0.42 38 19 25 N/A / 90 AFUE Z is/ 0.42 38 13 19 10 pA 18% 0.50 30 19 19 10 6 90 AFUE 1. ADDRESS OF PROPERTY: 144 l TG It E Z.L-f. 2. SQUARE FOOTAGE OF ALL EXTERIOR WALLS: �b GLA ZING• �. . ... 3. SQUARE FOOTAGE OF ALL � 4, %GLAZING AREA(#3 DIVIDED BY#2): 5. SELECT PACKAGE(Q--AA-see chart above): NOTE: OTHER MORE INVOLVED METHODS OF DETERMININGENERGY REQUIREMENTS ARE AVAILABLE. ASK US FOR.THIS INFORMATION. BUILDING INSPECTOR APPROVAL: YES: NO, q-forms-080303 a 780 CMR Appendix J Footnotes to Table J8.2.1b: Glazing area is the ratio of the area of the glazing assemblies (including sliding-glass doors, skylights, and basement windows if located in walls that enclose conditionedspace,but excluding opaque doors)to the gross wall area, expressed as a percentage.Up to 1%of the total glazing area may be excluded from the U-value requirement. For example,3 ft of decorative glass may be excluded from a building design with 300&of glazing area. 2 After January 1, 1999, glazing U-values must be tested and documented by the manufacturer in accordance with the National Fenestration Rating Council (NFRC) test procedure, or taken from Table J1.5.3a. U-values are for whole units: center-of-glass U=values cannot be used. 3 The ceiling.R-values do not assume a raised or oversized truss construction. If the insulation achieves the full insulation thickness over the exterior walls without compression, R 30 insulation may be substituted for R 38 -- _ . insulatio.n aiid IR-38 insulation-may be substituted-for-R-49 insulation: Ceiling R-values-represent-the-sum-of cavity....-...-. . insulation plus insulating sheathing (if used). For ventilated ceilings, insulating sheathing must be placed between the conditioned space and the ventilated portion of the roof. 4 Wall R values represent the sum.of the wall cavity insulation plus insulating sheathing(if used). Do not include exterior siding, structural sheathing, and interior drywall.For example,an R-19 requirement could be met EITHER by R 19 cavity insulation OR R-13 cavity insulation plus R-6 insulating sheathing. Wall requirements apply to wood-frame or mass(concrete,masonry,log)wall constructions,but do not apply to metal-frame construction. The floor requirements apply to floors over unconditioned spaces(such as unconditioned crawlspaces,basements, or garages).Floors over outside air must meet the ceiling requirements. The entire opaque portion of any individual basement wall with an average depth less than 50%below grade must meet the same R-value requirement as above-grade walls. Windows and sliding glass doors of conditioned basements must be included with the other glazing. Basement doors must meet the door U-value requirement described in Note b. 'The R-value requirements are for unheated slabs.Add an additional R-2 for heated slabs. ' If the building utilizes electric resistance heating use compliance approach 3;4, or 5.. If you plan to install more than one piece of heating equipment or more than one piece of cooling equipment, the equipment with the lowest .efficiency must meet or exceed the efficiency required by the selected package. 'For Heating Degree Day requirements of the closest city or town see.Table J5.2.Ia NOTES: a) Glazing areas and.U-values are maximum acceptable levels.Insulation R-values are minimum acceptable levels. R-value requirements are for insulation only and do not include structural components. doors in the building envelope a must have a U-value no greater than 0.35. Door U-values must be tested b) Opaque - alue ro cedure or taken from the door U v ted b the manu facturer in accordance with the NFRC test p and documented y in Table J1.5.3b. If a door contains glass and an aggregate U-value rating for that door is not available, include the glass area of the door with your windows and use the opaque door U-value to determine compliance of the door. ue eater than 0.35 . i.e. may have a U-value greater ) e door may be excluded from this requirement( y On Y crawls ace wall component includes two or more areas with wall slab-edge,of P P oor,basement , c If a ceiling,wall, fl � g -insulation levels the component complies if the area-weighted average R-value is greater than or equal to different insul P area-weighted average U- azin or door components comply if thegh g vent. GI P the R-value requirement for that component. g , q value of all windows or doors is less than or equal to the U-value requirement(0.35 for doors). 43 E,° : Town. of Barnstable Regulatory Services senHsrns , ` Thomas F:Geiler,Director ism Building Division Tom Perry, Building Commissioner 200 Main Street, I4yannis,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 ABuilder CD ,as Owner of the subject property :hereby authorise: e� �aZ to act on mEybehelf, in all matters relative to work authorized bythis building permit application for; (Address of Job) Signature of Owner . . 'Dat . �✓'Thv✓ �►TCC� Print Nance /ze -�'o7.vnia�uueall/c a�„�aas«,ctivaelta I ° • BOARD OF BUILDING REGULATIONS License: CONSTRUCTION SUPERVISOR yJ° Number:.CS 058764 Birth6te-=01/17/1958 4plme ,01717/2006 Tr.no: 15435 Restrlcfed:'00 M1 KEVIN A BAZARIAN PO BOX 689 W FALMOUTH, MA 02574" " i Acting CcVhmlsVoner 1 r Board of Building Regula ions and Standards One Ashburton Place -Room 1301 Boston, Massachusetts 02.108 Home Improvement Contractor Registration .� .4 Registration: 111271 i ., Type: Private Corporation 114 Expiration: 12/9/2006 BAZARIAN CONSTRUCTION CO IINCY KEVIN BAZARIAN PO BOX 689/ 90 COLONIAL WAY' W. FALMOUTH, MA 02574 -- ,d n� J Update Address and return card.Mark reason for change. ~�r Address ] Renewal ❑ Employment ❑ Lost Card DPS-CA1 0 50M-04104-G101216 3uL-t S 5 1 S 2. �S P T 2' / I . l� 'f i FL 1f 14 ° 1 I M� FLIAS H P /� r: . � 3� Mir To t-lou S6 V/ _ Zx 8 F , IZA � E P/T �o r POD wo„ Q�PosE7 Vd X ZZ FAt�aILY Z2-'o co Wo° i -�,C-MUVE WALL 3° Y — irl5z n�(S�ZX%O t36A,^ — 7'sl • To 13ECoME 1>I`,1n-LC-j ?,OOv\t\ _ �1CCZE VENTS V D V¢tP EDCF.- VENTS E>CIST�Nc� 1--iousb fly dl 7,C�� C(.EUtATkot-A . _ - }ZID4E VENT �- IZ10(-IE U6N7 \ I 1 /-1 SPH au e,T s PM wUL:r /ZuoF Ruut EjC(S-T I tkcj pr2V�UsEO — 6K«Sr I Le, ' 4{OVSE 9"DDIT101A / ND (Tt1uN /// I6T SLDEsinC- C—c.cv�ri�� C�Cyia; to �� r i I 171 CT N1 L �� — �P fit If r9 6 fe ..3r • I �� 13ns SENT ;� � •� ( I WAu ' I FoUNDWN ! I �K1 RETA%tkjR� WALL zoo`s SEE DsCra«.�I4" I wt T K S 2xlo RtaG� � 5�� LDx SNEAThk11�AG� ZyC to l6" U�C IZAT,TEZS l tATG-0 -Dzt�.cDc(E • PING FActra -okle WAt,L PINe ,SoFIT Ft2EE3E13oARLIP ` CEaAR Sll�tr`cc� 6% Ft zUtutss —TyvEy- NousE {h1SVLlgj.l0la —/ 14- C DX �'LYWUo-b S)4CA'�blli��C I-�LtwouD T Zxlb l6% �G �t c�o� JotsT ZA 1O "t AND SE'At— / f :r � AS"P�1ULZ SEAu.GoAT �uJhlDWilONI 4" 1111CIC SLW� �'� - ��' THICK E^'oVZ6a CUtJC WRt,[_, , q - ..TST 16 0 RAFTRZ FLOC3 c RAUKE 9k1- 1. FZAr 6- Noose / , G Assessor's offioe .0st floor): , ,Asse sor's map and lot number ,. ..`�.... o� .p�..�..b. M MUST Re. of THE ,, to Board of Healot� 6rd floor): l <�y Z,,,L ANC _ Sewage,..P,ernn t. )puri ber ...... '... ... WITH TITLE �'s®���� e 1�R ITH TITLE 5 = BAHd9TADLE. a. Engineerin� : aftm�nt (3rd floor): ro " a House ri+�"�ii r''.......................................` 5.. ................................. ''��'fl'MENTAL CODE ° � ie o.6\0m°' a yap ul I n'r r.t i''sl9 0s �� ;� APPLICATIONS 'PROCESSED 8:30-9:30 A.M. and 1:00-2:00 P.M. only OF BARNSTABLE _ ` �. lk 3 DING INSPECTOR !I \ W J i 'XPPLICATION FOR PERMIT TO ..�..axV.a.. — (/G............ TYPE OF CONSTRUCTION .. ......................................... 7._ .......................................1917 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: hP..•!L............ ....I .. ProposedUse .2.P...�C. .. ..N.... //9.L................................................................................................................................. ZoningDistrict ........................................................................Fire District .............................................................................. l Name of Owner rn .'.��37 5:...�� C?.TE'12.5 v/ ........Address .�.r. ..�1.�. �.he. G-I. 5...........��............ Name of Builder ....... L' r'�T..........Address ....:................... .. ................. Nameof Architect ............. ..................................................Address .................................................................................... Number of Rooms ... .................................................Foundation .�U2L'. ... /U G2E' G ........................ Exlerior ..........5,hloq.L.�`'..................................Roofing ..19 .i!1Q L3- v ........................................................... Floors ...T� . ....................................................................Interior ..�C P T 1 ... .. .....................`.\.......................................... Heating t! �. rn I �. I ........Plumbing T ...C.0..i�. ...... Fireplace ..................................................................................Approximate Costl�.d, e'S 9C7 Definitive Plan Approved by Planning Board ________________________________19________ . Area P.yam...!©. ..... Diagram of Lot and Building with Dimensions Fee ............................................. SUBJECT TO APPROVAL OF BOARD OF HEALTH �� ; / IN— ot — I _ y T a y V1 GJ LA � Q �\ . ` _. Obi - �� - � �,/� • I 19a� I i (26 / OCCUPANCY PERMITS REQUIRED FOR NEW DWELLINGS I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name .7i �...P."::.!,J,.CJ ..'...................... cj Construction Supervisor's License r�...... �..0.......... A PETL RSON, MR. & MRS. No :31037... permit for ADD TI,QN....._..... ;� S,itigle .Fam lv D -.11in .....................Hydzja&!q. .......M ..............:........... Owner Mr. & .., - tjrcon .... a.-.................................... Type of Construction vs. ..F.. ?. . ...................... Pe t PlotLot ............................... Permit Granted .......J..0 1-?...3.Q...............19 8 i Date of Inspection ....................................19 Ck Date Completed k 4 Assessor's offioe .Ost floor): Assessor's Tt�E ma o;pd, lot number �........ ......... ..°F to r Board of He'alot� (3rd floor): /� r� Sewage ,P.11 0.t' ; umber "....<.. � :. ......... rO 1, `. Z B9Hd9TODLE, t .. .. YAM Engineer fng �,apt��nt (3rd floor): � � 900 639, \e0' House, nt�rn rr y �aVA*f a• APPLICATION, RbCESSED 8:30-9:30 A.M. and 1:00•2:00 P.M. only tl TOW OF BARNSTABLE , 3� BTU LDIHG INSPECTOR �v-\ v3l --�-� ,--I APPLICATION FOR PERMIT TO .. ..OaU,S Tnt`C-, ��� T�/Y 9 .K o� ........ ............................................................................... . TYPE OF CONSTRUCTION ... U r���h -v 2� .................................. ............... ............................................ V�' .... ...................19 TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit according to the following information: Locationy 1`f��/V1L) S a.. ..:............................................,............ .................................................... ....)........ ..... ...... ProposedUse R e 5. .. e.N. .L................................................................................................................................. ZoningDistrict ........................................................................Fire District .............................................................................. �i12 d-/�il2S. ��Te2 6 .0 N eZ S7 /yi/ 7`c he GG -S Gli14 Nameof Owner ............................ .........................................Address ...................................... T�ialh�S J30JS ve12T Name of Builder ........................................................ ...........Address �.......� e/z r.,j S ...... ..........T........................................ Nameof Architect ........................................................"........Address .................................................................................... ... .�........................--.......................Foundation DUIZC' GoA) crzeTe Number of Rooms ............ ................................. .......... 1 , Exlerior .w.d O b S/J//U9L � t.Roofing .:/�5�.h1Q..L '`� ..... .......... ........................... ......................................... TAGt, EheeT'}CROC- Floors ......................................................................................Interior' r-leating e L l`..."..r�Z I.L...............................................Plumbing T... GU �.�......� ....e'er'........................ - _ �. . boa , Fireplace .::. ..............................................................................Approximate Cost�.. .de.................: ..................... ............... _ \ ........ . cn. Definitive•Plan Approved by Planning Board ___ _ ______________ 9________ . Area �`.7.�...... .��.... T..... Diagram of Lot and Building with;Dimensions ' Fee ........✓............................... SUBJECT TO APPROVAL OF BOARD OF HEALTH hg 0-6 j L o r tA y o -1t o 3 I ,�� of _�; ", • �Lo _ OCCUPANCY PERMITS REQUIRED FOR •NEW DWELLINGS / I hereby agree to conform to all the Rules and Regulations of the Town of Barnstable regarding the above construction. Name 7:4 + Construction Supervisor's License�.O.0..l ��......................... PETERSON, MR. & MRS. A=290-108 - Noj31037 permit for ..,,Addition ................ Single Family Dwelling Location 2.57. ....Mitchell. . . . ...... ...................... Way ` . .. . .... .. .... .. .... ..... Hyannis - Owner Mr. & Mrs. Peterson Type of Construction ..Frame ' ............................... 7 - .... ....................................................................... Plot ............................ Lot ...................'............ t - Permit Granted .....JUly...3.0........'........19 87 { Date of Inspection ....................................19 - Date Completed ......................................:19 Z. t . �oF Town of Barnstable *Permit# 9-/ ? • 1P,a O,e Expires 6 mo► k from Issue dal; &UMMARIA : Regulatory Services Fee ` ,o 10� Thomas F.Geller,Director Building Division Tom Perry, Building Commissioner "P -y - 200 Main Street, Hyannis,MA 02601 Office: 508-862-4038 �OfU Fax: 508-790-6230 T®II�� EXPRESS PERMIT APPLICATION - RESIDENTIAL QM OP, Not Valid without Red X-Press Imprint V Map/parcel Number Property Address Tch 19 U-6 W �-•l Rfeesidential Value of Work -a0Q, Minimum fee of•$25.00 for work under$6000.00 Owner's Name&Address ktC:rhu12 tiro Contractor's Name Telephone Number Home Improvement Contractor License#(if applicable) ' 9 Construction Supervisor's License#(if applicable) i ❑Workmen's Compensation Insurance ' Check one: ❑ I am a sole proprietor ❑4^am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's Comp.Policy# Copy of Insurance Compliance Certificate must be on file. Permit Request(check box) ❑ Re-roof(stripping old shingles) All construction debris will be taken to ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side Replacement Windows. U-Value (maximum.44) T?Q- U.),0,, *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc. ***Note: Property Owner must sip Property Owner Letter of Permission. Home Improvement Contractors License is required. Signature W>5t1 cs'�� Q:Forras:expmtrg Revise063004 The Commonwealth of Massachusetts Department of Industrial Accidents Office oflnuesUonUons 600 Washington Street, 7`h Floor - Boston;Mass. 02111 Workers' Compensation Insurance Affidavit:Building/Plumbing/Electrical Contractors name: address: city state: VY1 zip: o>-Ge i phone# �'3 2- ..`{-fig 570 Y work site location(full address): 21 am a homeowner performing all work myself. Project Type: ❑New Construction[]Remodel ❑ I am a sole proprietor and have no one working in any capacity. ❑Building Addition sum ❑ I am an employer providing workers' compensation for my employees working on this job. ^ Y'3d ' ' '';, y5 Sti'� �_•3 �5^+ .r 0..as7�'.�>' ? .. . r �t t k�l�i�..:'r�,��..s��$�Tx: .s•F,::hs,51. �6s•'� ��p...,r:���L.,'�,4k.,J.�:r ra.r:.A,:n.,..-x^ax:S-."�,L:n:; { �'a a •.•Sfh ,A} Sf S't �Cj \FS 8 � i iA R •Y� K71�-k �� +, f w�. TY. 4 ! ?d� '� h „� ,.n't.p5. �+ .' �"Y'a i2"E)•rs _ c �a .ram+i � ! .. �t r 7 k.'s,vq tt•„ ac7 - n«A a ` i „ ;�h,xQ+ri i. ysy- S .4 'C mti�a.. .� .,^5i�y�,•. c ;��"a,-� -�1 .4v rti<.-n..:'�.. .0. _ �.: aII$ttar a;:t n tYg.: xEv: s,•at�P-r�h c-N.Z.�a _ k a .' 4 . . �"�r,� �c -•8`.c i f ❑ I am a sole proprietor,general contractor,or homeowner(circle one)and have hired the contractors listed below who have the following workers compensationpolices: 9 _ . . Nil..>._.. _. a ,x..5=.... ... 1ro71tl1anv:IIalt18,3. ."�...........:,...+._-.<-- ,.:.. _ :.. ,,._ ....._ .,;. ..,_ tit -- .a - ..r..T•.-w' a'yD bI1E M. 3IISfiliifa'[I$e, x .:.,.,.... ' ,.:a ..•,w»:F,�., .,r....e.r .x...r .::.es�.:,.' 0�1$..r�... ' setfMi30n3'13�i�er. .. `�• ' 1 - y S 5 i t5 k b A GF .i' Y ('�•�1 } A'Y 7 3, �1.'� 1 Li,'F � •G � i 5 irrS�` .l'�i17�'�.1'�Fi�!_..-,..; .:.. .•�......�. ., r.. .:, . ., ••�`:._. .,..-..:;,,_ ..:�. U'�Y$...�1' 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 a copy of this statement may be forwarded to the Office of Investigations of the DIA for coverage verification. I do hereby certify unndder thepains and penalties ofperjury that the information provided above is true and correct Signature ( ?J Date a1°rv, l B a tsfl Print name VZeR-. r C, Phone# - 2- - S[ official use only do not write in this area to be completed by city or town official city or town: permit/license# ❑Building Department' ❑Licensing Board ❑check if immediate response is required ❑Selectmen's Office ❑Health Department contact person: phone#; ❑Other (revised Sept.2003) - S Information and Instructions Massachusetts General Laws chapter 152 section 25 requires all employers to provide workers' compensation for their employees. As quoted from the"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 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 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. Applicants Please fill in the workers' compensation 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 Department at the number listed below. City or Towns 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. The affidavits may be returned to 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 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,7`h Floor Boston,Ma. 02111 fax#: (617)727-7749 phone#: (617)727-4900 ext.406 �pfj►Elo Town of Barnstable *Permit# �P p� Expires 6 months from issue date BARMSTABM Regulatory Services . Fee 39. m° Thomas F.Geiler,Director Building Division Tom Perry, Building Commissioner X _PRESS 200 Main Street, Hyannis,MA 02601PERMIT Office: 508-862-4038 MAY 1 3 Z003 Fax: 508-790-6230 EXPRESS PERMIT APPLICATION - RESEQENTMMIQM1 bARNSTABLE Not.Valid without Red X-Press Imprint Map/parcel Number Property Address Residential Value of Work Owner's Name&Address Contractor's Name - Telephone Number Honig Improvement Contractor License#(if applicable) Construction Supervisor's License#(if applicable) ❑Workman's Compensation Insurance Check one: ❑ I am a sole proprietor �am the Homeowner ❑ I have Worker's Compensation Insurance Insurance Company Name Workman's.Comp.Policy# - 4 Permit Request(check box) Q],<e_-roof(stripping old shingles).All construction debris will be taken to r>�� cJ 41/J ❑Re-roof(not stripping. Going over existing layers of roof) ❑ Re-side ❑ Replacement Windows. U-Value (maximum.44) ❑ Other(specify) *Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.historic,Conservation,etc. ***Note: Pro erty Owner must si roperty Owner Letter of Permission. Signature Q:Forms:expmtrg ni . PLOT N CERTIFIED P L P LA LOCATION SCALE .�1/ Zn,'. .... .DATE /L/oi/,ZSLo03 PLAN REFERENCE .ids„•Silaw!�! ow, /?L.B.L:.BZ... . . . �� CERTIFY THAT TH-E �",R/STs�IG ,DWE'GG��!G, . 'T SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN HEREON. 1� DATE /✓os/,.Z�Zoo;3 f, a - 0 j O REGISTERED LAND SURVEY i REGIS � d o ti� 1 Ul Ir B j i GB OF EU69dARD G� r1q WCG-TT CD ELLEY o. 26100 p / ISTIL r P w D �AL L9N� t CERTIFIED PLOT PLAN SCALE . .�.��:.zn�. .... .DATE /Vo!�.ZSLoo3 PLAN REFERENCE 00 1 CERTIFY THAT THE ��!STs�IG DWELGL�!✓G SHOWN ON THIS PLAN IS LOCATED ON THE GROUND AS SHOWN HEREON 1 DATE �✓oy ZsZo�3 f, �. ° 0 0 REGISTERED LAND SURVEY i 'Ilk _ Z / o CI ti -tom `�H OF A!A / o ECdliPARD G,r E/ r/9 JAJ `r / ELLEY n CG^TT c- o. 26100 Po Il/D 9 'Es��'PEG1 ST ERAS 'a -x 1 CERTI FI ED PLOT PLAN + LOCATION jq,eNs�A�GE��(sjivwls�, , SCALE . /'is 2.0', . .DATE /1/a/..7.,,Z.00 3 PLAN REFERENCE . e7NG..Lo,T . F r � CERTIFY THAT THE SHOWN ON THIS PLAN IS LOCATED ON THE GROUND• AS,SHOWN HEREON. DATE i✓oy..2SLgv3 REGISTER ED LAND SUR f+ � 1 �� y .aoo s � o s q r - _ I. Ole G$ .� o ✓� • _ cC / � � N�i.��Y Yj � Z61G0 „o fss��fC/STtq`SJ� 9 a'AL LA'40 POND -. e`er s