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0190 OLD COLONY ROAD
BUILDING DEPT. Application nurnber.&:.:.0 o -/c;-)36 ............................. -Mff 1-4 HN Fee.....................lawl.,30 TOWN OFBARN8TABLE Building Inspectors Initials........... ................ NAM Date Issued;......�/............1.-.aoaa............................ SC "N F D Map/Parcel.... ......... ................. TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING[WINDOWS/DOORS/TENTS/STOVES/.WEATHERIZATION PROPERTY INFORMATION Address,of Project: 1.90 Old Colony rd Hyannis NUMBER STREET VELLAGE Owner's Name: Harry Baker Phone Number 845-893-3903 Email Address: Cell Phone Number Project cost$ 13,000 Check one Residential -X Commercial OWNER'S AUTHORIZATION As owner of the above property I h6reby authorize Suit n to make application for a building permit in accordance with 780 CMR I)pr)r Owner Signature: Date: rt1,AV, - TYPE OF WORK UF,&ARIVSrA Siding Q Windows(no header change)# 0 Insulation/Weatherization Doors(no header change)# - Commercial Doors require an inspector's review Roof(not applying more than I layer of shingles) Construction Debris will be going to S&J Exco Dennis CONTRACTOR'S INFORMATION Contractor's name BelCape Construction, INC Home.Improvement Contractors Registration(if applicable)# V1@R-/4?ff000(attach copy) Construction Supervisor's License# 106040 (attach copy) Email of Contractor belcapeinc@gmail.com, Phone number 508-685-9720 ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS IN A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE PERMIT CAN BE ISSUED. APPLICATION NUMBER............................................................ *For Tents Only* ..Date Tent(s)will be erectedt Removed on number of tents total Does the tent have sides?Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. Purpose of Event Check one:this event is a: for profit non-profit event Check one: Food served Yes No Flame Spread Sheet of each tent must be attached.Provide a site plan with the location(s)of each tent If food is being served at your event please obtain a Health Department approval between the hours of 8:00am-9.30 am or 3:30 pm-4:30prn. Commercial events may require Fire Department approval: *WOOD/COAL/PELLET STOVES Manufacturer# Model%I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side HOMEOWNER'S LICENSE EXEMPTION ` Homeowner's Name: Telephone Number Cell or Work number I understand my responsibilities under the rules and regulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable. Signature Date APPLICANT'S SIGNATURE Signa e Date All pernu pplications are subject to a building official's approval prior to issuance. 6 Any alteration or deviation from:above specifications mvolv�ng extra costs will be executed only upon wntten,orders and w*1i`become n extra charge over and above he estimate All agreements contingent upon strikes,accidents or delays beyond.our control Owner to carry fre,tornado.and other. necessary msurance up6A above work;,Workmen's Compensation.and Public I;iability Insurance on above work o betaken out by BELCAPE CONSTRUCTION;< C.No hen orsecurty interest will be pl..aced on the`:residence as a copse uence of the contract. Owners who secure their own q construction related perrriits or deal with unregistered contractors will be1 .''excluded fro cress to the guarantyfund. '. This.Contract not valid unless signed by Company Representative: --� - Acceptance=of Estimate ;= The above pieces,specifications and conditions are satisfactory and are hereby accepted BELCAPE CONSTRUCTION,INC`is authorized=to4do the work as specified: Contract total $ 3 If acceptable, initaal here � ' .'f .., .. Payment will be made as uch 1st Deposit 111 Start`da entvi Y P Yin Upon completion , Date< N Si atur s -; Note:No work shall begin prior to the:signing of the contract and transmtttal to the owner:of a copy of such contract You,the buyer may cancel:this transaction at any time vnorto midnight of the thud.busmess day after the day of this transaction Accepted By )ate-,. THIS PAGE IS PART OF AND`IN CONE ORI� ANCE`WITH PROPOSAL 190 Old Colony rd Hyannis Commonwealth of Massachusetts Division of Professional Lcensure. Board of Building Regulations,and Standards Constructot�` sr:Specialty CSSL 106040 Tres: 05/14/2020 ,# ANATOtI SI1/ TSK1 � 27 MILL PON6'RD � 4- WEST YARM604m MA. 02673 Commissioner. I t7 .ire^ c r f . i ` QfFCe Qf Consumer Affairs ands usmess`Reguia��on� 3 { y T ')' R& �., x x 1000 WaShtngtOn Sfree Surte 71fl r F a usell.3 Home I mprovemer V ctor Regis ration a r ^` +• 3 a �•� 1 k �} v- � �,kw„ x^��.s :7 r "�`^���{ �M -,� � �- - -y" a.aq p � s ,� ; B+ELCA/P�E^CQNSMCn-ON INC r vn 5 ,y� 7/�jJ N x s Y4 W�VMB�f7Y t1YG 1 �'r 3g; - :�, 4YDii A i 3 #' HYANNtS,MA 02601 x �� ma- IN r: T } 72 ....... man 'v x and Return Care sSCA 9 � 2DM�i5/17 <"t r M'�>4+��5� > .:�%��t✓tK i '��� �`'< ri < r �t's- ��r sr a-� � �"ra � �''� '! s k � } ; } a Elm �3 c '� JL 'Jdf,Ll6fLlJr ' (�IA"�iSQt — T.u^r ,zk ,fgIB .vs' Wo-y'+ a '24y"`'� z '.. WT a ffB{ES$t gif8,�AC88 t�$Yi2t�Ofl ti"*�'z z` c:�*' _ NONCE IMPROYEME►ITT C13NTRi1CT0R# k Reglstrati`on vatic!for indrvitlual use gniy M z tYf>i=�Cd�oaadott `+�`� before the+explratlon date ff found return to Y F:._ iratian � Office of Consume Affairs and Business Regulation k 1 02118/2022 1000 WBSfllnoton Street Su1te 710 ,; BELCAFaECON3�BUON Boston,MA 02118 Y Y 4 @N Mills b? any MIA Yw .. DENNISGRUS 42 WOODB@tRY AVESw �; i iYAivNis,lout 02801 � � e w - d4wthou#s gnature Man WN ;, � .•ar- �„ .�:,�� �,� �� � .+� r... - p " 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): BelCape Construction Address: 42 Woddbury ave City/State/Zip: Hyannis, MA 02601 Phone#: 508-685-9720 Are you an employer?Check the appropriate box:, Type of project(required): 1. ✓ I am a employer with 3 4. I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. New construction 2. ' I am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling ship and have no employees These sub-contractors have g• Demolition workingfor me in an capacity. employees and have workers' y p �'• t 9. Building addition [No workers' comp.insurance comp.insurance.required.] Electrical repairs or additions required.] 5. We are a corporation and its P 3. I am a homeowner doing all work officers have exercised their 11. Plumbing repairs or additions myself [No workers'comp. right of exemption per MGL 12. • Roof repairs insurance required.]t c. 152,§1(4),and we have no employees. [No workers' 13.✓ Other Roofing, Siding comp.insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees.. Below is thepolicy and job site. information. Insurance Company Name: AmGuard Policy#or Self-ins.Lic.#: R2WC181806. Expiration Date: 02/12/2021 Job Site Address: 190 Old Colony rd City/State/Zip: Hyannis, MA 02601 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cert�and a pains an pen s ofperjury that the.information provided above is true and correct Signature: �. Date: 5/12/2020 Phone#: 8-685-9720 Official use only. Do not write in this area,to be completed by city or town officiaL City or Town: Perm_ it/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#: R� CERTIFICATE OF LIABILITY INSURANCE ;,0, 2"a' ��. 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 polioy(ies)must have ADDITIONAL INSURED provisions or be endorsed. It 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 endorseme s. PRODUCERGONTA ALD : Victoria Sharapova 60A Brighton Avenue Agency Inc. PHONE , 617-787-7877 FAX 617-787-7876 60A Brighton Avenue No: Allston,MA 02134 E-MAILADD comm@aldinsurance.com INSURER(S)AFFORDING COVERAGE NAICa INSURER A: ATLANTIC CASUALTY INS CO 42846 INSURED Belcape Construction Inc INSURERS; AMGUARD INSURANCE COMPANY 42390 42 WOODBURY AVE Hyannis,MA02601 INSURERC: INSURER D: INSURER E• INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I`SR TYPE OF INSURANCE ADD SUBR POLICY NUMBER', POLICY EFF POLICY EXP - LIMITS - A Comm GENERAL LIABILITY L261002952 02/06/2020 2/06/2021 EACH OCCURRENCE $ 1.000,000 CLAIMS-MADE OCCUR DAMAGE TO RENTEDmom .. $ 100,000 MED EXP QtU oneperson) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY❑JJECT LOC PRODUCTS-COMP/OPAGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE UMrT $ Ea acc dent ANY AUTO BODILY INJURY Per( person) $ AUTOS ONLY AUTED OS ED BODILY INJURY(Per accident) $ HIRED NON-OWNED PROPERTY DAMAGE AUTOS ONLY AUTOS ONLY $ $ UMBRELLA LIAB OCCUR - EACH OCCURRENCE S EXCESSIJAB HCLAIMS-MADE AGGREGATE $- DED I I RETENTION S $ B WORKERS COMPENSATION R2WC181806 02/12/2020 02/12/2021 NA sTEATurE OTTH- AND EMPLOYERS'LIABILITY Y I N ER ANY PROPRIETOR/PARTNEWEXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMSER EXCLUDED? - ❑ NIA - (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 IDESCRIPPTIION OF OPERAnONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,.AddMonal Remarks schedule,trey be attadred If awre apace Is nequbed) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE- r-�,�.,,r�'• . 01W8-2015 ACORD CORPORATION. All rights reserved. ACORD 26(2016103) The ACORD name and logo are registered marks of ACORD ' TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map Z' Parcel ' ` Application # Health Division Date Issued Conservation Division \J� Application Fee Planning Dept. Permit Fee l D Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation / Hyannis Project Street Address r V-DW CO(O N Village �_.�. - _ •� _ --- ,: �` �}, Owner Address Telephone / ' 89 3 ' 39 D_3 Permit Request / Le42 f4 C Cn x /,$ / 4'1 Ci �C1'C fX Q 0 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation O Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family 0-1' Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: Orfull ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric ❑ Other, Central Air: ❑Yes llo Fireplaces: Existing New Existing,w od/coal_Move: ]Yes C9'14o -� -- Detached garage: ❑ existing ❑ new size—Pool: ❑ existing ❑ new size _ B : ❑ existing ❑'mow size_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size _ Otf 'r M�9 Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ co Commercial ❑Yes &Ko If yes, site plan review# rn Current Use Proposed Use APPLICANT INFORMATION (-BUILDER OR HOMEOWNER) Name Telephone Number Address YOB License.# s Home Improvement Contractor# 1 / 3-5 /3 Email Worker's Compensation #1 f J 08 -S 9L,6/g3--9- �t� ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO � - S ( O&VJS-0 (4 MIT/5 SIGNATURE DATE FOR OFFICIAL USE ONLY APPLICATION# ` DATE ISSUED" MAP/PARCEL N0: ADDRESS VILLAGE ' OWNER s " n DATE OF INSPECTION: FOUNDATION t FRAME INSULATION a. FIREPLACE i ELECTRICAL: ROUGH FINAL RLUMBING: ROUGH r o► % FINAL • z GAS: ROUGH `= FINAL FINAL BUILDING r � • DATE CLOSED OUT • J ASSOCIATION PLAN NO. s lne c:omrnonweaan oJmassacnuseus v . . Depa [meat of Industrial Accidents Oiwe of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavits BuUders/ContractorsMectricians/Plmnbers Applicant Information Please Print Le 'b Name(Business/organi on/tndM&aD: - Address: 7 61 C?C,C J rY City/State/Zip: Phone 7-e,2 B` G 8 s 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 PU3pIDYeeS(full and/or part-time).* have hired the sob-contractors 6. ❑New construction - 2. I an a sole proprietor or partner- listed one attached sheet 7. ❑Remodeling ship and have no employees These sob-confractors have 8. ❑Demolition working for me in any capacity. employees'and have workers' 9. ❑Building addition [No workers'comp.insurance comp,insurance i required.] 5. We are a corporation and its 10.❑Electrical repairs or additions officers have exercised their 3.❑ I am a homeowner doing aIl work ' 11.0 Plumbing sepias or additions myself [No woricers'comp. right of exemption per MGL 12. Roof repairs �]t c.152,§1(4),and we have no insurance re , employees.[No workers' 13.❑Other comp.insurance required_] *Any.applicant that cbecks box#1 mast also fill oat the section below showing their workers'compensation policy intnrmatiou t Homeowners who submit this affidavit indicating they are doing all work and then hue outside contactors must submit a new affidavit indicating such. #Coahaeinrs that check this box mast attached an additional sheet showing the name of the'sub-contractors and.strdr whether or not those entities have employees. If the sub-mmtractnrs have employees,they must provide their workers'cum.policy number. I am an employer that is providing workers'compensation insurance for my employees Below is the policy and job site information. Insm-ance Company Name: Policy#or Self-ins.Lic.#:7F. J U 3 5 3 4o6,1 ro.3 ^ Z Expiration Date: /0 Job Site Address p� (�"`7� (.�3� / City/Siabe%Lip: - LL�i Attach a copy of the workers'compensation policy declaration page(showing the policy numbe 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 violatgr. Be advised that a copy of this statement may be forwarded to the Of of Investigations of the DU for insurance coverage verification. I do hereby c under the pours and penalties of p that the in provided above is true and correct Date: Phone#: (v ��_6 <9 5�3 Offzcial use only. Do not write in dds area,to be completed by city or town official City or Town: PermitlLicense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.PIumbing Inspector 6.Other Contact Person: Phone#: I Information and Instructions Massachusefts General Laws chapter 152 requires all employers to provide wodkeas'compensation for their employees. Pursuant to Buis statute,an employee is defined as"._.every person in the service of another under any contract ofhire, express or imnplied,oral or written." An enTloyer 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 Iocal 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.accept able evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C()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 pemut 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 at must submit multiple per itllicense in applications any given year,need only submit it one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations is (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 cammercial venture (i.e.a dog license or permit to bum leaves etx.)said person is NOT required to complete this affidavit- The Office of Investigations would hke 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 Common�a th of Massachusetts Department of Iadustdd AoUdents office of Mvestigafiona 600 Washingtau St=t. Boa t MA 02111 Tel,if 617-727-4900 ext 406 or 1-07-NtASSAFE Revised 4-24-07. Fax#617-727-7749. www-mm pv1dia Town of Barnstable Regulatory Services BADI ram. HAS& Richard V.Scali,Director 039. �0 ,���► Building Division Tom Perry,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-403 8 Fax: 508-790-6230 Property Owner Must Complete and Sign This Section If Using A Builder I;� JL4d , as Owner of the subject property here4 auitLize -� ►� i41 to act on my behalf, in all matters relative to work authorized by this building permit application for. Ad ss of Job " "Pool fences and alarms are the responsibility of the applicant. Pools are not to be filled or utilized before fence is installed and all final inspections are performed and accepted. a -- Si na of Owner Signature o Applicant ( �I�r Ge Va 1 D Z Print Nime Print Name 1 Date Q:FORMS:O WNERPERMISS IONPOOLS Town of Barnstable Regulatory Services ` of r�ri, Richard V.Scali,Director o Building Division t Tom Perry,Building Commissioner Mass. seas. ��� 200 Main Street, Hyannis,MA 02601 �ED �s www.town.barnstable.ma.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: number street village "HOMEOWNER": name home phone# work phone# CURRENT MAILING ADDRESS: city/town state zip code The current exemption for"homeowners"was extended to include owner-occupied dwellings of six units or less and to allow homeowners to engage an individual for hire who does not possess a license,provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a one or two- family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner" shall submit to the Building Official on a form acceptable to the Building Official,that he/she shall be responsible for all such work performed under the building permit (Section 109.1.1) The undersigned"homeowner"assumes responsibility for compliance with the State Building Code and other applicable codes, bylaws,rules and regulations. _ The undersigned"homeowner"certifies that he/she understands the Town of Barnstable Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and requirements. Signature of Homeowner Approval of Building Official Note: Three-family dwellings containing 35,000 cubic feet or-larger will be required to comply with the State Building Code Section 127.0 Construction Control. HOMEOWNER'S EXEMPTION The Code states that: "Any homeowner performing work for which a building permit is required shall be exempt from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors);provided that if the homeowner engages a persou(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:IWPFII.ES\FORMSIbuilding permit fonnslEXPRFSS.doc Revised 061313 DEC-28-2014 05 :36 PM FOWLER r..- 978. 851 7981 P. 01 �q OLD colo 'v y � ' A`G WY A ►v rN i s a s'l V� z t 4 � o ► "7' ,2) x u� ALIL .... � ,,,�..s.�. ...r, �......, rk �.k A"� . w - Jerry) '•nsU I I-icensdai'se�!�F 4red 401 Ocean Street <4, Hyannis, MA 02601 l � 617-828-6853 PROPOSAL SUBMITTED TO PHONE C^ �C' DATE Ci3 3 / 2 Z STREET _ /J JOB NAME CITY�STATE and Zr CODE JOB LOCAP— PATE OF PLANS JOB PHONE ARCHITECT We hereby submit specifications and estimates for: leX 2-6 y 0,e,1�6kgoe-� Z�?Z�a-Z�7 �I i I I II MC prap05P hereby to furnish material and labor — complete in accordance with above specifications, for the sum of: i dollars(S 1 Payment to be made as follows. I' I All material Is guaranteed to be as specified All work to lo.competed in a workman. e manner according to standard practices.Any alteration or deviation from above specifications Authorized mvolving extra costs will be executed only upon written orders. and .w;l become an extra Signature w crarge over and above the estimate.All agreements contingent upon strikes, accidents or Note: h proposal may be delays beyond our control Owner to carry fire,tornado and other necessary insurance.Our withdrawn by us not accepted within days. \\ porkers are fully covered by Workman's Compensation Insurance. Arreptance of proposal— � The above prices.specifications Z11 and conditions gre satisfactory and are hereby accepted.You are authorized Signature 9736232988 Xerox 5755 04:08:15 p,m, 12-31-2014 1 /1 1 FILE No:,,ZLM LOT 7 40T: 3 PART: of 'LOT 2: Q REMAINDER OF p LOT 2 Q: is JADO i C7 ' K'f i� 1 OLD COLONY ROAD JWN s. LAUIOETAN{. u plotplans.com Silverstein&Silverstein 71 Lm&n FatkwAy.3rd Floor ) . .:DUS L:AURIERS Hrorkwa,MA 02301 &WSOCIATFS)NC. Ftlooe s014587-ot4z 420 TORTTTNIS BODUWARD WLFORD.MA M757 Fix:509-588.266T ...... .-..... . isoDYasY-ReoD PAx:{Boe)Blx-Sou° MORTGAGE INSPECTION PLAN THERE AREOVE 40 DEEE�EOE ASMENTTS IN OR ADDK$$;j,9D 0L0 ENCROACHMENTS WITH RESPECT To LENDER: - DWELLING SITUATED ON THIS LOT AT ATTORNEY. WR5TEIN dt CREEDON 8597 RECCORo SHO �ON THE DUD OF $E OMER:AM A, dt PAULINE CHEVALIER TTIE LOCATION OF THE DIELUNG AS APPLICANT:HARRY.AND LINDA C. BAKER SHORM HEREON EMER WAS IN DATE: 1 3 SCALE 1':201 .CCIJNTY;,)jA({�{$J(tiBl COMPLIANCE MATH THE LOCAL ZONING BY^LAW5 IN EFFECT WHEN UNREGISTERED LAND CONSTRUCTED(NTH RESPECT TO STRUCTURAL SETBACK REOWREMENTS 'rLOOD HAZARD INFO% DEED BOOK:4()97 PAGE 309 ONLY),OR IS EXEMPT FROM NOLATION LOVE; PLAN BOOi(:7S. PACE: - ENFORCEMENT ACTION UNDER MASS,G.L. �_DA'IED:JM� nc4. L LOt{5):.� dE PT,� VILE'Al.CHRPtER 41M,SECRON 7, . COMMUNITY PANEL:.. Q:e.--+'x i. PLAN NUMEIER:_,_„-,,:,,,.�-,,,,�._-_•.._.•____OF 7HE LOCATION OF THE DM£TUNG SHOWN REGISTERED LAND CERTIFICATE OF TTLE:.... .. ... DOES NOT D A SPECIAL FLOOD HAZARD ZONE, EXCEPT AS MAY RECISTRATRX7 BOLh: iAi _ i ASSESSORS MAP:-32L,_. BE INDICATED. PLAN NUMBER:- ...........__......,._..... BLOCK: 1k— LOT:_ _ • ....•...__.. GENERAL,NOTES (S)THE DECLARATIONS MADE ABOVE ARE ON THEBASIS OF MY KNDMZDM,INFORMATION,AND 8EUEF AS 1HE RESULT OF A MORTGAGE INSPECnoN TAPE SURVEY;P:<!t ;a gi'rx* ? 't..VL71'�kPNI!fL' "' MADE TO THE NORMAL STANDARD OF CARE OF RED57ERED LAND SURVEYCRS PRACTM.MG IN MASSAC{iUSETTS.(2) OEMARAP.ONS ARE MADE TO THE ABOVE NAMED CLIENT ONLY AS OF THIS DATE.(3)THIS PLAN WAS NOT MADE FOR RECORDING PURPOSES.FOR USE IN PREPARING DEED DESCRIPTIONS OR FOR CONSTRUCTION.(4)VERIFICATIONS OF PROPERTY LINE DIMENSION%BUILDING OFFSETS,FENCES,OR LOT CONFICJRATION MAY BE ACCOMPLISHED BY AN ACCURATE INS1RilLOT StiRVEY. 5 NO RESPON5ly!UTY 15 ASSUMED HEiFJN TO THE LAND OWNER OR OCCUPANT, Copori0i W.V4,6m lwom 6 Amcc.Im, Cape Save Inc. - 7-D Huntington Avenue . South Yarmouth, MA 02664 Tel: 508-398-0398 Fax: 508-398-0399 2/19/13 kAj Town of Barnstable Thomas Perry CBO ' . cn Building Commissioner " 200 Main St.Hyannis,MA 02601 RE: Building Permits rn Dear Mr. Perry, This affidavit is to certify that all work completed for 190 Old Colony Road,Hyannis has been inspected by a certified Building Performance Institute(BPI)Inspector. Ceiling: R-30 cellulose in open ceilings & R-19 cellulose in enclosed slopes Walls: R-11 fiberglass & R-7.2 Thermax in knee walls Basement: R-19 fiberglass box sill All work performed meets or exceeds Federal and State Requirements. Sincerely, William McCluskey 4 TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map 3 S Parcel .b 1 Application #C240 rC;l 0 Health Division Date Issued 2 1�4 1 Conservation Division Application Fee + Planning Dept. Permit Fee 3S Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address 110 014 Colony Rd Village H qam',5 Owner 9 o a er C e v�y]i e t' Address 1'am r Telephone S09 - :nS - 6�a. Permit Request Q Ik- 30 cell W10Sp "Fa e a �'c. ,�1Aerwe -1G Co& so a a,nI re6- - VLnos Pt�11 R-19 ��becgLaS3 *0 48 6mmmg bnr, cl'l- Nt, sea` -F E kwic 1I8nP GtiA bofflglI- UY 5,11IuulA 0-x0an, i�ni &AA1. Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new Zoning District Flood Plain Groundwater Overlay Project Valuation43, 1Q0 Construction Type Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation. Dwelling Type: Single Family ❑ Two Family ❑ Multi-Family (# units) Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes ❑ No Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) Number of Baths: Full: existing new Half: existing new Number of Bedrooms: existing —new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas ❑ Oil ❑ Electric Other M i Xe Central Air: ❑Yes 09 No Fireplaces: Existing New Existing wood/coal stove; ❑S3 ❑ No Detached garage: ❑ existing ❑ new size_Pool: ❑ existing ❑ new size _ Barn: CV?kisting Q3new-size'`_ Attached garage: ❑ existing ❑ new size _Shed: ❑ existing ❑ new size — Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ - Commercial ❑Yes �ft No If yes, site plan review# Current Use Proposed Use APPLICANT INFORMATION z (BUILDER OR HOMEOWNER) +.I' rr Name Wi �i m r� e e� Telephone Number �6� ��qg -D N nn Address an�-�ny�-an T�'Y8 License # ZC In 1). Sou.-1- LnOXAL 1' ►tom 0 akl w Home Improvement Contractor# I Worker's Compensation # —ty C 3 3 l 80o4- ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE DATE d• r FOR OFFICIAL USE ONLY APPLICATION# DATE ISSUED MAP/PARCEL NO. i ,! 't ADDRESS "' VILLAGE - .. OWNER- DATE OF INSPECTION: -" FOUNDATION FRAME F INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL r PLUMBING: ROUGH FINAL GAS: ROUGH FINAL = f FINAL BUILDING DATE CLOSED OUT 4 ASSOCIATION PLAN NO. t 7 f � i ! U. The Commonwealth of-Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,4 0-7111 wwiv.mass.;ov/dig Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leo-ibly Name(Business/Oranization/Individual): n dI.YC n C Address: - D Ht *111gkOn �vrrflK,� City/State/Zip:5ou`4' Y-JEMOIJA mA WU4 Phone#: 50$_- 3 0 0 3 9 ? . Are you an employer?Check the appropriate box: 4. I am a general contractor and I Type of project(required): 1.9 I am a employer with k� ❑ b . employees(full and/or part-time).* have hired the sub-contractors 6 ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g• Demolition working for mein.any capacity, employees and have workers' [No workers'comp.insurance comp.insurance.+ 9. ❑Building addition required.] 5• ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doingall work officers have exercised their 1 l.[]Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12 Roof repairs insurance required.]f c: 152,§1(4),and we have no `` employees.[No workers' 13. Other 1' g�,1 a i on comp.insurance required.] *Any applicant that checks box RI 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 contactors must submit a ne%v affida�itindicating such: ,Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. lam an employer tltat is providing workers'compensation insurance for my employees, Below is the policy and job site informatioir. Insurance Company Name: TP_ n010 4 TnS% r0.i1oC ' Policy#or Self-ins.Lic.#: T W C 3 3[ 8 Expiration Date: y 7 13 " Job Site Address: q0 . h City/State/Zip: f q,nA Is (� Attach a copy of the workers'compensation poll y declaration page(showing the policy num r 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 S1,500.00 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certi,f,under the pains and pettrrlties of perjury that tite iraforruation proi,ided abo�e ' true and correct Signature: (ri IU�� O' Date- Phone 9: 50 8 - 3 9 8 - 0 3 c7 , Official trse onir'. Do trot write in tltis area,to be completed by ciq,or to►f•n official , City or Town: Permit/License Issuing Authority(circle one) 1.Board of Health 3.Buildinj Department 3. CitylTown Clerk 4.Electrical Inspector 5.Plumbin;'Ilispector 6. Other Contact Person: Phone=: AC40 CERTIFICATE OF LIABILITY INSURANCE 11/9/2012 T� 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 terns and conditions of the policy,certain policies may require an endorsement.. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Shannon Sperrazza Risk Strategies CompanyPHONE (781)986-4400 AIC No:(781)963-4420 15 Pacella Park Drive E-MAIL .ssperrazza@risk-strategies.com Suite 240 INSURERS AFFORDING COVERAGE NAIC# Randolph MA 02368 INSURERA:Selective Insurance INSURED INSURERB:Safetv Insurance Companv 33618 Cape Save, Inc INSURER c-.Technolocry Insurance Co an 7 D Huntington Ave INSURER D: INSURER E: South Yarmouth MA 02644 INSURER F: COVERAGES CERTIFICATE NUMBER:CL1211954576 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR A DL SUB POLICY EFF POLICY EXP LIMITS TYPE OF INSURANCE POLICY NUMBER MIDD MM D GENERAL AD LIABILITY EACH OCCURRENCE S 1,000,000 D AGE OR N D S 100,000 X COMMERCIAL GENERAL LIABILITY PREMISES occurrence A CLAIMSME XO OCCUR 199448001 0/16/2012 0/16/2013 MED EXP(Any one person) S 10,000 PERSONALBADVINJURY S 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG S 2,000,000 X POLICY PRO- LOC S AUTOMOBILE LIABILITY Ea a ED SINGLE LIMIT 1,000,000 BODILY INJURY(Per person) $ B ANY AUTO ALL OWNED SCHEDULED 6208200 1/6/2012 1/6/2013 BODILY INJURY(Per accident) S AUTOS AUTOS PROPERTY DAMAGE $ NON-OWNED (Per accident) X HIRED AUTOS M AUTOS X Underinsured motorist RI split $ 100 000 X UMBRELLA LIAR OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE AGGREGATE S 1,000,000 199448001 0/16/2012 0/16/2013 $ DED RETENTION C WORKERS COMPENSATION officers excluded XJTORY WC LIMITS-L ER OTH- AND EMPLOYERS'LIABILITY YIN from coverage E.L.EACH ACCIDENT $ 500 000 ANY PROPRIETORIPARTNERIEXECUTIVE❑ NIA B OFFICERIMEMBEREXCLUDED? rc 3318007 /9/2012 /9/2013 E1.DISEASE-EAEMPLOYE $ 500,000 (Mandatory In NH) If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500 000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Issued as evidence of insurance. Issued as evidence of insurance. National Grid Corporate Services LLC d/b/a/ National Grid, Action Inc. , Colonial Gas Company and NStar Electric are listed as additional insureds as respects General Liability as required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Cape Light Compact PO BOX 427/SCH AUTHORIZED REPRESENTATNE 3195 Main Street Barnstable, MA 02630 Michael Christian/SMS B-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) ©198 INS025 ignimm ni Tho At non name onel Innn%ra ranicforeel morlrc of Artnwn �Iassachusctt - Department of Public Safe'N of Building_ Rc�lulatiunx 11nt1 Standards Construction Supervisor Specialty License License: CS SL 102776 Restricted to: IC WIL•LIAM MC CLUSKY 37 NAUSET ROAD WEST YARMOUTH, MA 02673 Expiration: 6/2812013 Tr: 102776 ( ,nuui••i,ncr 74 Office of Consumer Affairs and usiness Regulation c 10 Park Plaza- Suite S 170 1, Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 171380 -- Type: Corporation Expiration: 3/1412014 Tr# 222184 CAPE SAVE INC. - WILLIAM MCCLUSKEY = = 7-D HUNTINGTON AVENUE SOUTH YARMOUTH, MA 02664 = Update Address and return card.Mark reason for change. -_ ; Address Renewal 1 Employment Lost Card PS-C41 C1 5oM•04104-G1U1216 �%1e lfl mnioxweal�. d' Ila acluae%s License or registration valid for individul use only Office of Consumer Affairs&B siness Regulation before the expiration date. If found return to: HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation Registration: 171380 Type' 10 Park Plaza-Suite 5170 ''Mla= Expiration: 3/14/2014 Corporation Boston,MA 02116 CAPE SAVE INC.'. ,. WILLIAM MCCLUSKEY 7-D HUNTINGTON AVENUE 4� _ SOUTH YARMOUTH,MA`02664 Undersecretary Not valid wit o signa 460 West M a'D Str-et T ASSISTANCE ,, EVER HOME REPAIR '` (508) 771-5400 F (.505)79 -242 _ CORPOR N TT-'r on :ill lines un•€J"r.L'AxonL:apec-'.3d.or HOME OWNER WEATHERIZATION WORK PERMIT&FUEL RELEASE: PLEASE FILL OUT AND SIGN THIS FORM IF YOU ARE THE APPLICANT HOME OWNER. I 6� &HuAia 1 hereby consent to and agree.that weatherization work may be done by the Weatherization Program of Housing Assistance Corporation{ herein after referred as "Agency an the property located at: " The weatherization work done will be based on programmatic priorities and availability of funding and it may inclo.de all or some of the following measures: Weather-stripping &caulking of windows and doors, insulation of attics,sidewalls&basements,attic and other ventilation measures and possibly replacement of badly deteriorated windows.In consideration of the weatherization work to be done at my home I agree to the following: 1. I give permission to the "Agency" its agents and employees to travel onto or across said property with such equipment and materials as may be necessary to perform weatherization woxk on said property. 2. The:Housing Assistance Corporation reserves the right to inspect the fuel or utility bill for the weatherized unit on an ongoing basis for no more than five(5)years after the weatherization work is completed. . I have read the provisions of this agreement as listed and freely give my consent. Home Owner: (Signature) Date: Agent: (signature) Date: } \_ HAC approved Weatherization Company: Cu Caliber Building&Remodeling Cape Cod Insulation Cape Save Creswell Construction Frontier lergy Solutions Lohr& Sons Peter Smith Resolution Energy a Rock Solid Construction All Cape Insulation R M r ,TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION' Map 7 Parcel Permit# ��85�-r Health Division t Date Issued Conservation Division Fee Tax Collector • Treasurer -/-/ Planning Dept. Date Definitive Plan Approved by Planning Board' Historic-OKH Preservation/Hyannis Project Street Address Village Owner I e-Q!ew Address 5�:dV C-' Telephone 7?S= t Permit Request s'i/mil 7;' f�� ;1Zo 2 r� Square feet: 1st floor: existing proposed 2nd floor:,existing proposed Total new Estimated Project Cost Z -.70 Zoning District Flood Plain Groundwater Overlay Construction Typef Lot Size Grandfathered: ❑Yes ❑No .If yes, attach supporting documentation. ` . " 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 F Basement Finished Area(sq.ft.) Basement Unfinished Area(sq.ft) Number of Baths: Full:existing ',new Half:existing new Number of Bedrooms: existing new Total Room Count(not including baths):existing new First Floor Room Count Heat,Type and Fuel .❑Gas ❑Oil ❑Electric ❑Other Central Air: ❑Yes ❑No Fireplaces: Existing New Existing wood/coal stove: ❑Yes ❑No Detached garage:❑existing ❑new size", Pool:❑existing ❑new size Barn:❑existing ❑new size Attached garage:❑existing ❑new size Shed:❑existing ❑new size Other: Zoning Board of Appeals Authorization ❑ Appeal# Recorded❑ Commercial ❑Yes OrN� If yes,site plan review# Current Use Proposed Use BUILDER INFORMATION Name X�i �`✓4f.10 e-le Telephone Number -7 6/ Address X ---7// x License# ✓ /�'� ���'%GI�}lG Home Improvement Contractor# /a 5-' 1 1 Worker's Compensation# ` ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BETAKEN TO .tea u-/� �✓�? .92 SIGNATURE DATE _ L FOR OFFICIAL-USE ONLY PERMIT NO. y « ;C• DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTIOI FOUNDATION FRAME INSULATION FIREPLACE � � ' _. � w i •- E � .4'~ '_ - - .� � ELECTRICAL: ROUGH FINAL :s t PLUMBING: ROUGH f FINALrk { GAS: Y. ROUGH FINAL' FINAL BUILDING' ' { DATE CLOSED,OUT _ ASSOCIATION PLAN NO. i t '7 Building Mvision 367 Main Street,Hyannis MA 02601 ffice: 508-862-4038 , Ralph Crosses ax: "S-790-6230 Building Commissio: e- 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 strncutres which are adjacent to such residence or building be done by registered contractors,with certain exceptions,along with other requirements. Type of.Work: Estimated Cost—? Address of Work: '- 'fa e l Owner's Name: c=,t e r��i�,�li��`/• Date of Application: I hereby certify that: Registration is not required for the following resson(s): Q Work excluded by law Job Under S1,000 Building not owner-occupied [30wner pulling own permit Notice is hereby given that: OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED CONTRACTORS FOR APPLICABLE HOME 151PROVEMENT WORK DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL c. 14ZA. SIGNED UNDER PENALTIES OF PERJURY I hereby apply for a permit as the agent of the owner.- Date Cont a=Name _ Registration No. OR Date, Owner's Name q:forms:Affidav 600 WashingtonStreet Boston,Mass. 02111 Workers' Compensation Insurance Afridavit nnc:aE�Trsfizrasaatxtr;:;�'�'�/��.'�/i.,�///////�///%/���/////.����" � �•.�•�--- name: 6 location. city � �b�Z ❑ I am a homeowner performing all work myself nphone � 7 �' Q j1 am sole proprietor and have no one wot�Cins'in anv ca achy I am an employer providing lvorkers' compensation for ray employees tvoridng on this job• fcomnnnv name: � �v�, < •• .• • I'addre!iv ell city' iitsurnnce cn. I am a sole proprietor, general contractor, or homeowner circle one and have ai•e hired the contractors listed below who the folloi%ing ivorkcrs' compensation polices: ' omnnnv name- ddre�lr done «w«... ::c. ,. v ivrnnce cn. :.: ^. iii�r# i% �7nrry name- :.:':•`':' .: ` 'r:.y ' t•�^�a; r ; ;�.. :: i atone#i • •' r:' ......... .. :•:a.. licv# L zv to secure t:overage as required under Section ZU of MGL 152 can lead to the Ira ean; tsnprisonment as well AS civil penaidw in the form of a STOP NVORK ORDER and o[�p��oia rt M up to 52300. d and/or r of this statement maybe forwarded to the Ohre of Investigations of the DU for covemce vertliodon• N�tree I tmdesatsad that a hrrrby crrtif}•trader the azns pena&=of prrjurp that the information pravrded above is&me=dCVJ7C .ature /'�`�-�• Date �� � at name TG��G l� 25 0-7�_ Phone# tIldsi use only do not write in this area to be completed by city ortown offid-I tv or town: pettnit/ll a QBttilding Department check if in�tediate response is required � `Board • ❑Sdeeanm's )M start person: Mealth Department phoned; ❑Other _ _ . cmvioyees.. As quoted from the "law", an employee is defaced as every person in the service of another uncle:My c; 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 orthe foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, orthe:rcr: trustee of an individual , parmership, association or other legal entity, employing employees. However the onmer of a dweffi m house having not more than three apartments and who resides therein, orthe occupant of the dwelling house c: another who employs persons to do maim e , constmaron or repair wow cm such dwelling house or an the_gT :_ c: 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 reae7r, of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who not produced acceptable evidence of compliance with the insurance coverage required. Additionally,neithe.•the commonwealth nor any of its political subdivisions shall eater into any contract for the performance of public..work ut :i: acceptable evidence of compliance with the insu ce requirements of this chapter have been presented to the cm=c-= authority. Applicants Please fill in the workers' compensation affidavit completely, by checking the box that applies to your situation and suppiying company names, address and phone numbers along with a cmtifrczte of insurance as all affidavits may be submitted to the Department of Industrial Accidents for canfirmatinn ofins . date the affidavit. The affidavit should be returned to the crw=-d atthe fie' Also be sure to sign and �' application for the permit or lic....se is bemg requested, not the Department of Industrial Accidents. Shmsid you pave nay questions regarding the law"or if J c :are required to obtain a workers' compensation.policy,.please=11 the Deparmzmt at the number listed below. FEE City ar Towns Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of affidavit for you to fill out in the event the Office of Iavestigatiaes has to camact you regarding the applicant. Plerse be sure to fill in the pc=iuIiccase number which writ be used as a ref===cumber. 7hc affidavits may be rcuanea ro ;he Department by mad or FAX unless other arrangements have be=made. Ilse Office of Investigations would Lice to thank you in advaece for you epoperation and should you have nay questions. :lease do not hesitate to give us a call. [he Deparm='s address, telephone and fax number. The Commonwealth Of Massachusetts Department of Industrial Accidents 0mce of Imrastlpetlons 600 Washington strent Boston;Ma. 02111 • fax#: (617) 727-7749 phone #: (617) 7Z7-4900 eat 406, 409 or 375 ��-� ✓fce tvayrar��aruuecc�t uy'✓��.�L:c��►��.��� � ' i :HOMER IMPRQVEM0NT CONTA i6T6RS REG.ISTRATI_UN oard of Building Regulations and standards One Ashburton Place — Room 1301 ! ��`r�gti L� ti, a oft ass huss tpts,Q21QE3� r:, �; •.,s 'iR`; uT"b �..'� . ; 4 ,, �` 4. >(:i ,..- <..:ir!., ",: ��,r. _.; t.f. .(IA�sJ• �. '. }3A �6...�'T�J'7� •:1. �u1^�1ME IMPRO.VELMENT C0 4. m s�. - / S� '1 4t ResafaiaYf�$9I ., . F r�.r '.WG ,� i;'�{ -%..:a t t� �U r' .. ,i� :•r' '� i r .�. .a�f r ♦. f7 TOCAkNIVMttlrlvlUli �:�� ;�tf ��. .•. t , ,fi ,. _ kOME' IRPROVEMENT CONTRACTOR k«A _ Registration lOb 7 e A': K• a z�� j INDIVIDUAL � THEODORE L : HITCHCOCId Expiration 06%21/00 . ky}'vta;`t y PO BOA.'. t9k� y('1:1 Y-i -��+1Y^' l� l .'� / 1(... � T .i...( YAl BARNSTABLEw MA 0668 w 4° .. THEODORE L. HITCHCOCK PO BOX 211% 55 LISA LN' . a-BARNSTABLE MA 02668 A0IAINISTAAMR i w ' I C ? 7 (` � � lg �rgly , RE-ROOFING ❑ ' If located in OKH or Hyannis Historic District- Certificate of Appropriateness required unless same color/same materials specified on application Map/parcel number I Sign-offs from: -- ❑ Tax Collector Treasurer E29of squares of shingles or square footage of roof to be shingled specify stripping old shingles or going over old roof. If going over ❑how many roof layers existing now ❑what size are rafters? What is span? ❑ Complete dwelling information for the Assessors Dept. -if known Signature ✓[� Workman's Comp. form Home Improvement Contractor Affidavit(RESIDENTIAL ONLY) Home Improvement Contractor's License OR ❑ Homeowner's License Exemption(RESIDENTIAL ONLY) Check expiration date on license COMMERCIAL WORK-No License is required. Fee q-forms-PERMITS I Rev3/5/99