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0014 PAINE AVENUE
GU ' � Town of Barnstable P' � ih�Card So Th��a� ���:,w,.-u, _, be Retained on Job and Building ost This at it is Visible From the Street p w T• eet-Approved Must this Card Must be Kept RARN5CARlE. - - MASS. $ Posted Until Finallnspection Has Been Made. - .bs� .� ; _ Permit r ° ,Where a Certificate of Occupancy is Required,such Building shall Not be Occupied until a Final Inspection has been made. Permit NO. B-19-3023 Applicant Name: HOMEOWNER IS APPLICANT Approvals Date Issued: 10/10/2019 Current Use: Structure Permit Type: Building-Alteration INTERIOR Work Only- Expiration Date: 04/10/2020 Foundation: Residential Map/Lot: 288-144 Zoning District: RB Sheathing: Location: 14 PAINE AVENUE, HYANNIS Contractor Name: HOMEOWNER IS APPLICANT Framing: 1K qy-.?/ re ol Owner on Record: EWING,BRAXTON D,&DOS SANTOS, Contractor License: EXEMPT 2 Address: 14 PAINE AVENUE Est. Project Cost: $3,500.00 Chimney: HYANNIS MA 02601 ; Permit Fe 85.00 L Insulation: ays d Description. Adding a Half Bath a n d Laundry y _ ( Fee Paid $85.00 Final: Project Review Req: Date 10/10/2019 Plumbing/Gas Y P Rough Plumbing: This permit shall be deemed abandoned and invalid unless the work authorised by this permit is commenced within six months after issuance. Final Plumbing: All work authorized by this permit shall conform to the approved application and the'approved construction documents for which this permit has been granted. All construction,alterations and changes of use of any building and str'ucturesshall be in compliance with the local zoning by=laws and codes. Rough Gas: This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. Final Gas: pia The Certificate of Occupancy will not be issued until all applicable signatures b.the'Building and Fire Officials are rovid p y pp g y g p ed on this permit. Electrical Minimum of Five Call Inspections Required for All Construction Work*, Service: 1.Foundation or Footing 2.Sheathing Inspection Rough: 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection Final• 5.Prior to Covering Structural Members(Frame Inspection) 6.Insulation Low Voltage Rough: 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical installations. Work shall not proceed until the Inspector has approved the various stages of construction. Health "Pers ns con rac ' with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c'.142A). Final: Building plans are to be available on site Fire Department All Permit Cards are the.property of the'APPLICANT-ISSUED RECIPIENT Final: Application Num Jq... .�,�/..................... TOWN OF BARNSTABLE MASS. g Permit Fee.'............. .......................Other Fee:.......:............... 059. l119 SEEP 13 AM 8; .5 7 � ' TotalFee Paid.......... :. ............................................ ... ....... �1...... l�l� f� TOWN OF BARNSTABLE . Permit Approval by....... ..:..... .on......... .. BUILDING PERMIT Map.............. .... ...............Parcel...... ....... ............................. APPLICATION Section 1 — Owner's Information and Project Location Project Address I Paine /-ve- Village bityoenn is Owners Name r CR- 4-0 n r1 Owners Legal Address ILA P a t h .P— Av -p- City i3or r\4o,61 ,e State /tl,+ Zip ©3.60 l Owners Cell# 5 R 7 7 e{0 H2� E-mail we cc i a C Section 2 —Use;of Structure Use Group ❑ Commercial Structure over 35,000 cubic feet' ❑ Commercial Structure under 35,000 cubic feet ❑ Single/Two Family Dwelling, Section 3 —Type of Permit ❑ New Construction ❑ Move/Relocate '❑ Accessory.Structure ❑ Change of use ❑ Demo/(entire structure) ❑ Finish Basement ❑ Family/Amnesty ❑ Fire Alarm Rebuild ❑ Deck Apartment ❑ Sprinkler System g/�Addition ❑ Retaining wall ❑ . Solar y ,` Renovation ❑ Pool ❑ Insulation Other-Specify Section 4 - Work Description Add n ela Uri Jr, 1� Tort,,-,4.+.A• 11/1,znni9 � r Application Number...................................................... Section 5—Detail Cost of Proposed Construction-—- e Footage of Project 5 O Age of Structure I Q Dig Safe Number # Of Bedrooms Existing Total#Of Bedrooms (proposed) 2 110 MPH Wind Zone Compliance Method .❑ MA Checklist ❑ WFCM Checklist ❑ Design Section 6—Project Specifics ❑ Wiring ❑ Oil Tank Storage ❑ Smoke Detectors ❑ Plumbing ,❑ Gas ❑ Fire Suppression ❑ Heating System ❑ Masonry Chimney ❑ Add/relocate bedroom F Water Supply ❑ Public ❑ Private Sewage Disposal ❑ Municipal. ❑ On Site Historic District ❑ Hyannis Historic District ❑ Old Kings Highway a Debris Disposal Facility: I am using a crane ❑ Yes ❑ No Section 7—Flood Zone Flood Zone Designation l Within or adjacent to a wetland, coastal bank? Yes ❑ No ❑ Section 8—Zoning Information i f Zoning District Proposed Use Lot Area Sq. Ft. w I Total Frontage Percentage of Lot Coverage #of Dwelling Units (on site) Setbacks Front Yard Required Proposed i Rear Yard Required Proposed Side Yard Required Proposed Has this property had relief from the Zoning Board in the past? ❑ Yes ❑ No Last updated: 11/15/2018 Ca 1 " 75 CL i • C `� O � � � _ _ , V _ ,� �- 00 . _ � _4.. _ W �� .__ _. � . g �lCp ' / The Commonwealth of Massachusetts Department of IndustridAccidents 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): Dr-ocX a-Ctia-, L cD aan a Address: i LA Pco n.`)P— A-y-e- City/State/Zip: 1 n a 1 Phone#: Are you an employer?Check the appropriate bog: Type of project(required): 1.❑ I am a employer with- 4. [] I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. E]Remodeling ship and have no employees These,sub-contractors have g. Demolition working for me in any capacity. employees and have workers' # 9. �Building addition [No workers' comp.fro ce coW insurance. 10.0 Elechrical _repairs or additions ed. 5. We are a corporation and its rep 3 I am a homeowner doing all work officers have exercised their 11.[]Plumbing repairs or additions j Irr myself[No workers'comp. right of exemption'per MQL 12.❑Roof repairs insurance required.]t c..152,§1(4),and we have no. employees.[No workers' 13.❑Other comp.insurance required,] `Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#:. Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'"compensation policy.declaration page(showing the policy number and expiration date). Failure to secure coverage as required under-Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year.imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against-the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Sign /'`r� c.0 t Date: &2 Phone"#: S O`8 7 3 7 0/©44 3 1 OjJicial use only. Do not write in this area,to be complded 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.EIectrical 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 iri 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 regnired." 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 numbers)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 inst rance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents O fflee of Investigations 600 Washington Street Boston,MA 02111 - Tel.#617-727-4900 ext 406 or 1-877-MASSAF.. Revised 4-24-07 Fax#617-727-7749 www:maw.gov/dia Application Number............................................. Section 9 Construction Supervisor Name Telephone"Number Address City State Zip License Number License Type . Expiration Date Contractors Email Cell # I understand my responsibilities under the rules and iegulations for Licensed Construction Supervisor in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your license. Signature _ Date Section 10-Home Improvement Contractor i Name - Telephone Number Address City State Zip Registration Number Expiration Date I understand my responsibilities under the rules and regulations for Home Improvement Contractors in accordance with 780 CMR the Massachusetts State Building Code. I understand the construction inspection procedures,specific inspections and documentation required by 780 CMR and the Town of Barnstable.Attach a copy of your H.I.C... Signature Date Section 11 -Home Owners License Exemption Home Owners Name: j rC_X o r1 w I n �a —v i Telephone Number ,�©9 7 3 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 bptt k ��„4,,,--- -Date. 51e _j APPLICANT SIGNATURE Signature / 41aRk_Cn ZL,u 2 Y7 Date I �d (q Print Name `,rax o —LZ uo Y1�j Telephone Number E-mail permit to: Last undated: 11/15/2018 ^Y Section 12 ' Department Sign-Offs Health Department ❑ Zoning Board(if required) ❑ Historic District ❑ Site Plan Review(if required) ❑ Fire Department ❑ �' Conservation ❑ For commercial work,please take your plans directly to the fire department for approvak Section 13—Owner's Authorization i L , 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 ,w • t Last updated: 11/15/2018 ., Town of Barnstable Building. s s6�39 ► PktrT,:«°h��iU=",�3 nCtailr:e."dF�eln Saol,�TI:;nh s�apt eia.tc1.ait,:sio:•�U`nikscH�it�a;..'lse,�B,F..e.reo�nm M t.zha_'.e,_dtt eS et roPan M �ae R"ea tedos�s,e ilkead on5 lob and this'Card Muis„t3�b e fiK�r:e t Permit Wh ,..>3aE�. ., ..�,�;�=! u_>...Y ee,z..�a_>o.,�.�.. .�^^�'�' �.>.,� .,.i,�:k«A•.K,a :�:2,sx.'�..,�,.,.,. ....�3....M-...,.n_e_�.... Permit NO. B-18-2909 Applicant Name: EWING, BRAXTON D&DOS SANTOS, NICHOLE Approvals Date Issued: 09/10/2018 Current Use: Structure Permit Type: Building-Siding/Windows/Roof/Doors Expiration Date: 03/10/2019 Foundation: Location: 14 PAINE AVENUE,HYANNIS Map/Lot 288 144 Zoning District: RB Sheathing: Owner on Record: EWING,BRAXTON D& DOS SANTOS, Contractorame Framing: 1 Address: 14 PAINE AVENUE Contractor Lice�nse4 2 �° HYANNIS, MA 02601 �< Est Project Cost: $0.00 n Chimney: Description: Replacement Door(1) Permit Fee: $35.00 M Insulation: Fee Paid $35.00 Project Review Req: Date 9/10/2018 Final: � , Plumbing/Gas Rough Plumbing: � R Building Official ;, • Final Plumbing: This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within sixmor the after issuance. Rough Gas: All work authorized by this permit shall conform to the approved application and the""approved construction documents:for%which this permit has been granted. : r All construction,alterations and changes of use of any building and structures,shall be in compliance with the local zoning by laws and codes. Final Gas: N This permit shall be displayed in a location clearly visible from access street or roatl and shall be maintained open for public m�spectwn for the entire duration of the work until the completion of the same. W,, f I Af Electrical The Certificate of Occupancy will not be issued until all applicable signatures I*the Building and Fire Off cial are provided onthis-permit. Service: Minimum of Five Call Inspections Required for All Construction Work:-, 1.Foundation or Footing Rough: 2.Sheathing Inspection 's 3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Final: 4.Wiring&Plumbing Inspections to be completed prior to Frame Inspection 5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Rough: 6.Insulation 7.Final Inspection before Occupancy Low Voltage Final: Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations. Health Work shall not proceed until the Inspector has approved the various stages of construction. Final: "Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGL c.142A). Fire Department Building plans are to be available on site Final: All Permit Cards are the property of the APPLICANT-ISSUED RECIPIENT Application numbe ............................................... +� R Date issued.......................................... ...... ,► ,. ,+ 161 sk J Nib Building Inspectors Initials.......f..... ......................... �P -Map/Parcel. ....................` ..................... TOWN OF BARNSTABLE EXPEDITED PERMIT APPLICATION: ROOF/SIDING/WINDO WS/DOORS/TENTS/STOVES/WEATHERIZATION PROPERTY INFORMATION Address of Project: I N Q %n e, G,V& ► ctYld1 S NUMBER STREET VfLLAGE Owner's Name: 3 rgAo n i=w i n!1 Phone Number Email Address: Cell Phone Number Project cost $ 1,5O > 00 Check one Residential Commercial OWNER'S AUTHORIZATION As owner of the above property I hereby authorize to make application for a building permit in accordance with 780 CMR Owner Signature: QnA. _ Date: 'See &fn b4- " T TYPE OF WORK 0 iding 0 Windows (no header change)#- F-1 Insulation/Weatherization - EZ Doors (no header change) # Commercial Doors require an inspector's review 0 Roof(not applying more than 1 layer of shingles) - Construction Debris will be going to CONTRACTOR'S INFORMATION Contractor's name Home Improvement Contractors Registration(if applicable)#. (attach copy) Construction Supervisor's License# (attach copy) Email of Contractor Phone numberQ ALL PROPERTIES THAT HAVE STRUCTURES OVER 75 YEARS OLD OR IF THE SUBJECT PROPERTY IS I A HISTORIC DISTRICT, YOU MUST OBTAIN HISTORIC APPROVAL BEFORE A PERMIT CAN BE ISSUED. I APPLICATION NUMBER.............................................................. *For Tents Only* Date Tent(s) will be erected Removed on number of tents total Does the tent have sides? Yes No (If yes please attach floor plan with exits marked) Dimensions of each Tent X X X Additional tent dimensions can be attached on a separate piece of paper. 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-4:30pm. Commercial events may require Fire Department approval, *WOOD/COAL/PELLET STOVES Manufacturer# Model/I.D. Fuel Type Testing Lab Offsets from combustibles: front back left side right side -- — -- HOMEOWNER'S LICENSE EXEMPTION Homeowner's Name: 1-- l n Telephone Number O �'_3 `0 13 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 I Date APPLICANT'S SIGNATURE Signature g2l tw= Date All permit applications are subject to a building official's approval prior to issuance. I � 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): � C.� Address: i ave- A-ve - ( gants City/State/Zip: l7' n6 Ck(Phone#: TO Y 7 3 ` 0 3 Are you an employer?Check the appropriate box: Type of : ret ec j ro (required): 4. am a general contractor and I p ( q ) 1.El I am a employer with ❑ I g 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition workingfor me in an capacity. employees and have workers' Y P t3'• 9. ❑Building addition o workers' comp.insurance comp.insurance.$ 5. We are a corporation and its 10.❑Electrical repairs or additions requued.] 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.[_1 Other comp. insurance required.] *Any applicant that checks box#I must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. #Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct Signafore: CA-) t Date: e 1407 'P4l` Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: r 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=apph'cation=for-the=permit=or-license=is=being-requested;not=the=Department of = -- Industrial Accidents.—Should you have-any-questions-regarding the-law or ifyoware-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 incomplete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address,telephone.and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents office of Investigations 600 Washington.Street Boston,MA 02111 Tel.# 617-727-4900 ext 406 or 1-877-MASSAFE Fax#61.7-727-7749 Revised 4-24-07 www.mass.gov/dia TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Q Map �`� v Parcel Application # . i Health Division Date Issued Conservation Division Application e Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address t'CA-IkL Village //` 4MI co A! Address I� Telephone,x 4; SQL • 775 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed ® Total news Zoning District Flood Plain Groundwater Overlay C ,,Project-Valuation` L5 Construction Type Lot Size /D. Q'e /�: Grandfathered: ❑Yes ❑ No If yes, attach suppo Ring tcumentation. Dwelling Type: Single Family M/ Two Family ❑ Multi-Family(# units) 7-1 Age of Existing Structure Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes wri�o Basement Type: Zull ❑ Crawl ❑Walkout ❑ Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) 220 Number of Baths: Full: existing I new Half: existing new Number of Bedrooms: Z existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑Gas (!I'O it ❑ Electric ❑Other Central Air: ❑Yes trNo Fireplaces: Existing New Existing wood/coal stove: ❑Yes dI No Detached garage: ❑le-xisting ❑ new size_Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size 29 ex _ Attached garage: isting ❑ new size _Shed: ❑existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current.Use. Proposed Use _ APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name .,, ,,� % Telephone Number 72 Address y5, &Iae ia lot o°Qs�/ License # Home Improvement Contractor# Email •� � f c ° �: J orker's Compensation # ALL CONSTRUCTION DEBRIS KIESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE ./ DATE FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED MAP/ PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL E PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDIN DATE CLOSED OUT ASSOCIATION PLAN NO. APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name / 7, Telephone Number y D� 7.2 Address 1Z�� License # Home Improvement Contractor# Email f c orker's Compensation # ALL CONSTRUCTION DEBRIS KIESULTING FROM THIS PROJECT WILL BE TAKEN TO SIGNATURE , DATE �� ,"- TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION Map v Parcel Application # f Health Division Date Issued Conservation Division Application e Planning Dept. Permit Fee Date Definitive Plan Approved by Planning Board Historic - OKH _ Preservation/ Hyannis Project Street Address ,Village - .._ ,I�.AAAAMX if nerd/�vT.��/ cs.v e,► Address I f rTelephone FO r—Permit,Request7 ,7�� Lf _,,al >i2 Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Q Total new Zoning District Flood Plain Groundwater Overlay ,Project Valuations A5 CO Construction Type 03 Lot Size /D. �a Cam^ Grandfathered: ❑Yes ❑ No If yes, attach support g umentation. IF / CA d7i Dwelling Type: Single Family Two Family ❑ Multi-Family(# units) 5 Age of Existing Structure yA.9 Historic House: ❑Yes ❑ No On Old King's Highway: ❑Yes Llo Basement Type: Full ❑ Crawl ❑Walkout ❑Other Basement Finished Area (sq.ft.) Basement Unfinished Area (sq.ft) ?ZO Number of Baths: Full: existing I new Half: existing new Number of Bedrooms: Z existing _new Total Room Count (not including baths): existing new First Floor Room Count Heat Type and Fuel: ❑ Gas IM'Oil ❑ Electric ❑Other Central Air: ❑Yes ErNo Fireplaces: Existing — New Existing wood/coal stove: ❑Yes d1 No Detached garage: ❑/existing ❑ new size—Pool: ❑ existing ❑ new size _ Barn: ❑ existing ❑ new size_ Attached garage: 9 existing ❑ new size _Shed: ❑ existing ❑ new size _ Other: Zoning Board of Appeals Authorization ❑ Appeal # Recorded ❑ Commercial ❑Yes ❑ No If yes, site plan review# Current Use_ Proposed Use ` APPLICANT INFORMATION (BUILDER OR HOMEOWNER) Name , \r� =ram �<<P C�c�S� Telephone Number 0 Address Pad License#�_ O)G � Home Improvement Contractor# Email c Wo 's Compensation # ALL CON UCTION DEBRIS RESULTING FROM THIS PROJECT WIL TAKEN TO SIGNATURE A DATE �_] ,� FOR OFFICIAL USE ONLY APPLICATION # DATE ISSUED MAP/PARCEL NO. ADDRESS VILLAGE OWNER DATE OF INSPECTION: x FOUNDATION FRAME INSULATION FIREPLACE ELECTRICAL: ROUGH FINAL PLUMBING: ROUGH FINAL GAS: ROUGH FINAL FINAL BUILDIN �IZJ%B-7 C DATE CLOSED OUT ASSOCIATION PLAN NO. 77m Comurarnveakh qfJ&Ysadrrsetis Pepartmwt lud strid Accideds . 6V O Eras ingtou 19keet - Bastva,AM 02111 ' tt��vfurtlgrrv�iiia •< lrt'MIMFe CGMPens3cm InsnUMce Affidavit:EtdlderslCtmtractarsMech ciansThmihers A HcaIId Inforniat hn Please prin Nam owiu�.izz�R 'a : :YL-11 Address: <�k �z i ckr -y, W�` UWStatMq*- - Ph,o Areyou an employer?Checkthe appropriateb= ' TTpe of project r L❑ I am a to 4 am a getreral contractor-and I e f eq consfxu�on P * luve hired the s��kmt�s 6. ❑Ides employes(full an&ior park-Time)- 2.❑ I am a sale prcpuetmr orparfaw- listed amthe.attached she t. 7 ❑Remodeling nese smb-- tars hale slap and have flo eaaployeefi • $.,❑Demalifaoa wry la andhace wo�rsT ++Q far.�ae in any capacity. employees $i 9. ❑S,uilding addition, . [No SPdt rS' camp.rraa�reanr� CC p-ingRr� ,k-) . ❑ We are a cotpomfion and ifs 1 D❑Elet;t�ical repairs or ad aas required-] 5- 3_❑ I am a homeomer doing all work Of rkers have exerr_iced their 1 L❑Plumbingrepairs ar additions. seM o wadcm' t of emaraption Per M&- ❑ +s a=e etpred_]T c.152,§I(4k 1..and Roof repairs employees-I O WCIA ors' 1311 Other conxp_insaran�e mquire&] •saYappfi�BzSccbea3tw:fl eLsafino f se oabeTaw a�a�aieawu�Cea'mmp tiaffporuyi rm �ffameowaets who sahnrit iris afiida<<u yarra+m p trey aze•daia�alf Wa�c and tbea hne aatside coatractarsnmst submit a new�dazyt i sadi �>l�t.amnktotsthxt ehecki sboxmost stiacl ur 9dditi®sl-she simwingtbe'nmeof ma soli-canb=6xs ffid 0ft*he�arnotrlmse eaitimbne_J emg3aye�.Ifthe m�-c�,�,+*s�,�h�•e emPiaS�s;tfiey�stgmv�de#3�.�irworkers'gyp:p'aT�atm�seL • I nut ara etxploysr Heat is pra��iding n�ar&ers'courperesrdimt uisurartca or rri�*¢mPIQ3�e Rabov is Yltepa-Iicy and job site hif6t7tra an. 7 TnsurancecampanyName: h?—I V` -Paficy 4 or Self-ins.Zle_ Job 5t)--14,ddres l'^�t�}/�Q� L`7.VL Cily/S#afet is r Attach a copy of the workers coaupeusafionpoRcrdeclaration page(showing the policy,mrmh and ezpiration date). Failure to secure coverage as requiredunder Section 25A of MGL• a 157—can lead 10 the imposition,of critn+nai penalties of a firm up to$UDDOG and ar one-year imprison as w6n as civil penalties,in the farm of a STOP WORK ORDERaitd a floe of up to$250-00 a day against the violator. Be adiised t a copy of this statement.xnaybe forwarded to the Office of Investigations of the DIA.for ihsuraace coveMF y a IrtaIfengbyc aa andpgrut mofpajittythatMeinfonnadouprm abmaisttare and correct Sitmature: Bate e' Phone sFl. O,(Tchd use anTy. Da ttotwrtts in tfds ar€a ter be cmnpTetdd dry dry ortoirn ojokiat City or Taww. Permiff icense# Issuing A,ntlsor€ty*(circle one): L Board of Health y ceding Department 3.City1rown Clerk 4.Electrical Inspector S.Pbrmhimg Inspector 6.Other Contact Person: Phone#: �� G eberal Laws chapter 152 r&qm-=all:=3pI0y=t3 provide wolfs'compMMzfion far ffick employeM Pm•sasot:to this Vie,an=47kT=is defined as¢:evezg peason fn a service of another�dex nay CO S°f � expreW or huplied,oral or wrsffrm..7 association,corporation or oti>e�Legal eMf[Ly,or UY two or more AnIr�yer is defined as man indrvidna�P � �of a derxased employer,or$ie of the faregomg engaged in a joint ,and inclndmg the legal=pees receim or tus'tee of main drvfdnal p ,asociaiinn or offierIegal entity,�oyMg�IDy�- However the owner of a dweII%og house having not more than tll=.apartments and.-Who resides theme,or the occapaut of tbi--- dw Ma house flf another who employs persons to do zaa ce,rrn,eFrrtr Fi on or repay wow on such dwelling house or on-the grounds or bm7dmg agp lhedD sballnotbecause of sorb=ployuneutbe deemed in be an eraployea." MC`rI,chapter 152.§25C(6)also sties thn-everystate,or local£ieemin agencyskaRwiffihold$ie issuance cr renewal of a Ikea se or permit to operate a baseness or to mnstmct bnadhV in the commonwealth for any applicjnf who has notproduc ed acceptable evidencm of compHanm WiM the hmurance-coverage raqukel. Addtdonally.MGM❑hapt=152,§25�stags¢I�Teither the eor®�we-a�i nor arcy of ifs political snbcTitLe,fi 7;aacl. enter ink�9 contact far the Perfoml�ce ofpublio wok u�I acceptable evidence of compliancewhh the req=emefs of dais d3apt=have been.preserlfedtn the mnft g.anfho> iy:' Applicaat-s . Please flI o $ie wow'c°mPeasat i Dn affidavit completely,by chec? �boxes�apply to your situation and,if necessary,supply sub-c s)na ne(s), addresses)andpbonenumber(s)aIongwlthth==tEffc2fe(s) of or Ua ited.LiabMtyP s CLEF)withno eanpIoyees Other than the . instance. LnmitodLiabl7ity Comeanies(LLG� members or pa=inexs,are not itqaard to can:Y wa±nre congm- iian.insaran= If an LLC or LLP does have empIoyees,apolicyisreqnfitZ Beadvbredthd this atfidaYitmaybesnbmifedtutbeDepaitm=tofludusfrial Accidents for confirmation of fnsnrance coverage Also be sure to sign and datethe aftdavit: The affidavit should be•rttnmed to the city or town that the appficzflm for the permit or license is being requested,not the Df_-partmenf of Ln stri a1_A,.ccide=ir, gMuRyou,have any questions regmdm g fiie law or if you are regrmed to obtain a wo k=' compensationpolicLplease can ffioDeparfine�atflennmbeslist dbelow. Self-fimuedeampanies should.en�rt$efr ur � self-insd„ IlCeoso number on the lane. City or Town Ot.fEciaTs Please be sore that the dadavh is campIete andpr�ed Legibly. The Depar�entbas provided a space at:t ie bottmn out in the event the Office oflnv has to confazt of the affidavit for youto you regarding the applicant P Leas a be dare to fill the 11 it/E=se rucaber which.w1M be used as a=fm=ce u=ber.In addition,an applicant $st must submit multiple permitum e;applit:ations in any given year.nee&only submit one affidavit g current p olicy mfomaation.[if necessary)and under`gob�e Ada=e the applicant Fhot<Id write�aII Locations>n ( Y°L town):'A copy ofthe affidavitii�athas been officiallyP Stamped or mmkedbythe city or town may be provided to the applicant as pmofthat a valid affidavit is on film for fixtar 'pemits or hmme- Anew affidavit Est be filled oil earls year.Where a home owner or citia is obta�g a license or pe=it not related fo any btzsi a=or commercia.1 Cie.a.dog li=wc orpeuaitto buraIcwes etc-)said person is NOT required to COmPlete f3is affidavit The office of Investigations would I1ke to thank you in adce for your coopean and sb°uldyon have any questions, please do not bj!:! tcto give MS a C, al The Departmaaf 9 address,telephone and fax lnanber: + e C=M=,w=II*of �af�id�ia�Aot�.den� tom=Of Tnvedzeatio= • �4 man � T(�_L 0 GI7— -4 cxt 406 car 1477 MA'M+ Fax 617`27 7M Keviscd424--)7 ww Mwgu z� r AWC Guide to Wood Construction in Sigh Wind Areas:110 rnph Wlnd Zone Massachusetts Checklist for Compliance(780 CMR 5301.z.1.1)1 Check. 1.1 SCOPE Compliance WindSpeed(3-sec.gust)..........:............................::...:.......:....:....... ......t.............:............................110 mph WindExposure Category..........:......................:...................::.......:.. .... ........................:...............:..........:..B 1.2.APPLICABILITY Number of Stories(a roof which exceeds 8 in 12 slope shall be considered a story) stories 5 2 stories RoofPitch ........:.................................................................(Fig 2)..........:................................ 512:12 MeanRoof Height ..............................................................(Fig 2)................ .. ................... ft.:5 33' BuildingWidth,W............................... ................... ...(Fig 3). ...................................... . .. _ft 5 80, Building Length,L .....(Fig 3).............................:. _ ' Building Aspect Ratio(L/W) ...............................................(Fig 4). ................. is3:1 Nominal Height of Tallest Opening2 ...................................(Fig 4).........:...................................... <-618. 1.3 FRAMING CONNECTIONS General compliance with framing connections..............:..:..(Table 2).......................:........................................ 2.1 FOUNDATION Foundation Walls meeting requirements of 780 CMR 5404.1 Concrete.................................................................:......................................:..................... Concrete Masonry........................................................................:........................... .. 2.2 ANCHORAGE TO FOUNDATION''3 5/8"Anchor Bolts imbedded or 518"Proprietary Mechanical Anchors as an alternative in concrete only Bolt Spacing-general....... ..... ........(Table 4). .. ........................... .... .... in. Bolt Spacing from endroint of plate ..:..........................(Fig 5). ....................:............ in.<_6"-12" Bolt Embedment-concrete......................7--....***"*(Fig 5).............................................. in.2:7" Bolt Embedment-masonry...............................................(Fig 5):........................................... in.>:15" Plate Washer...............................................................(Fig 5 z 3"x 3"x Y4" 3.1 FLOORS Floor framing member spans checked :.................:............ per 780 CMR Chapter 55)..z................................. Maximum Floor Opening Dimension. ............................ .(Fig 6). .............................................. _ft 512' Full Height Wall Studs at Floor Openings less than 2'from Exterior Wall(Fig 6)........................................ Maximum Floor Joist Setbacks Supporting Loadbearing Walls or Shearwall.:..............(Fig 7)....................................................—ft 5 d Maximum Cantilevered Floor Joists Supporting Loadbearing Walls or Shearwall................(Fig 8)...............,......................................._ft 5 d Floor Bracing at Endwalls................................................:..(Fig 9).............................................................. Floor Sheathing Type ........................................................(per 780 CMR Chapter 55)...........................:........ Floor Sheathing Thickness ............... (per 780 CMR Chapter 55).................... in. �F Floor Sheathing Fastening. ................................................(Table 2)..._d nails at in edge/_in.field 4.1 WALLS Wall Height Loadbearing walls. .........:..........................................(Fig 10 and Table 5)......................... ft 519 Non-Loadbearing walls.:..:.............: .......(Fig 10 and Table 5).................... ... ft 5 20' •....r............• .... Wall Stud Spacing ........................................................(Fig 10 and Table 5)...................—in.:524"o.c. Wall Story Offsets ........................................................(Figs 7&8)........................................... ft 5 d 4.2 :EXTERIOR WALLS' Wood Studs Loadbearingwalls........................................................(Table 5)..............................2x ft ` in. Non-Loadbearing walls..........................6.....................(Table 5)..............................2x_-_ft_in. Gable End Wall Bracing ' Full Height Endwall Studs.. ........................................(Fig 10). ...... ...................................................... WSP Attic Floor Length...............................................(Fig 11)................ ..:. .............. ft zW/3 Gypsum Ceiling Length(if WSP not used)..................(Fig 11)............................................_ft z 0.9W and 2 x 4 Continuous Lateral Brace @ 6 ft.o.c. . (Fig 11).............................. ......... ........... . .... or 1 x 3 ceiling furring strips @ 16"spacing min.with 2 x 4 blocking @ 4 ft.spacing in end joist or truss bays Double Top Plate Splice Length ........................................................(Fig 13 and Table 6)...................................... Splice Connection(no.of 16d common nails) ............(Table 6). ...................................................... AWC Guide to Wood Construction in High Wind Areas:110 mph lend Zone ; Massachusetts Checklist for Compliance(780 CMR 5301.2.1.1)` Loadbearing Wall Connections Lateral(no.of 16d common nails)...............................(Tables 7)...................................................... Non-Loadbearing Wall Connections Lateral(no.of 16d common nails)...............................(fable 8)........................................................ Load Bearing Wall Openings(record largest opening but check all openings for compliance to Table 9) Header Spans ........................................................(Table 9).................................._ft_in.511, SillPlate Spans ........................................................(fable 9).................................._ft_in.s 11' Full Height Studs (no.of studs)...................................(Table 9)........................................................ Non-Load Bearing Wall Openings(record largest opening but check all openings for compliance to Table 9) HeaderSpans.......:.....................................................(fable 9).................................._ft_in.512' Sill Plate Spans...........................................................(Table 9).................................._ft--in.512° Full Height Studs(no.of studs)....................................(Table 9)........................................................ Exterior Wall Sheathing to Resist Uplift and Shear Simultaneously, Minimum Building Dimension,W Nominal Height of Tallest Opening2 ............................................................ ............ _s 6'8° SheathingType.............................................(note 4)...................................................... Edge Nail Spacing.................................:.......(Table 10 or note 4 if less)....................... in. FieldNail Spacing.........................................(Table 10)................................................. in. Shear Connection(no.of 16d common nails)(Table 10)..................................................... able 10 % Percent Full-Height Sheathing......................(T ). ...... ............................................_ 5%Additional Sheathing for Wall with Opening>6'8°(Design Concepts)..................... Maximum Building Dimension,L Nominal Height of Tallest OpeningZ.........................................................................._r.618° SheathingType.............................................(note 4)...................................................... Edge Nail Spacing..........................................(fable 11 or note 4 if less)....................... in. Field Nail Spacing.........................................(Table 11)................................................. in. Shear Connection(no.of 16d common nails)(Table 11). .................................................... _ Percent Full-Height Sheathing.....................(Table 11)........... ...................................... _% , 5%Additional Sheathing for Wall with Opening>6'8°(Design.Concepts)..................... Wall Cladding Ratedfor Wind Speed?............................................................................................................................. 5.1 ROOFS Roof framing member spans checked?.......................(For Rafters use AWC Span Tool,see BBRS Website) Roof Overhang ...................................................(Figure 19)............. ft_<smaller of 2'or U3 Truss or Rafter Connections at Loadbearing Walls Proprietary Connectors Uplift................................................(Table 12)............................................U= plf Lateral.............................................(Table 12)..................................... L= plf. Shear..............................................(fable 12)............................................S= plf Ridge Strap Connections,if collar ties not used per page 21... (fable 13)...............................T= plf Gable Rake Outlooker.........................................(Figure 20).............._ft s smaller of 2'or U2 Truss or Rafter Connections at Non-Loadbearing Walls Proprietary Connectors Uplift................................................(Table 14)............................................U= lb. Lateral(no.of 16d common nails)...(fable 14).......................................L= lb. Roof Sheathing Type...................................................(per 780 CMR Chapters 58 and 59) ............ Roof Sheathing Thickness........................................... .............................................. in.z 7116°WSP RoofSheathing Fastening...........................................(Table 2).......................................................... Notes: 1. This checklist shall be met in its entirety,excluding the specific exception noted in 2,to comply with the requirements of 780 CMR 5301.2.1.1 Item 1. If the checklist is met in its entirety then the following metal straps and hold downs are not required per the WFCM 110 mph Guide: a. Steel Straps per Figure 5 b. 20 Gage Straps per Figure 11 c. Uplift Straps per Figure 14 d. All Straps per Figure 17 e: Comer Stud Hold Downs per Figure 18a and Figure 18b- 2. Exception:Opening heights of up to 8 ft.shall be permitted when 5%is added to the percent full-height sheathing requirements shown in Tables 10 and 11. 3. The bottom sill plate in exterior walls shall be a minimum 2 in.nominal thickness pressure treated#2-grade. AWC Guide to Wood Construction in Milt WindAreas:110 mph Wind Zone Massachusetts Checklist for Compliance(780 CMR 5301.2.1.1)` 4. a. From Tables 10 and 11 and location of wall sheathing and Building Aspect Ratio,determine Percent Full-Height Sheathing and Nail Spacing requirements b. Wood Structural Panels shall be minimum thickness of 7/16°and be installed as follows: 1. Panels shall be installed with strength axis parallel to studs. ii. All horizontal joints shall occur over and be nailed to framing. iii. On single story construction,panels shall be attached to bottom plates and top member of the double top plate. iv. On two story construction,upper panels shall be attached to the top member of the upper double top plate and to band joist at bottom of panel.Upper attachment of lower panel shall be made to band joist and lower attachment made to lowest plate at first floor framing. v. Horizontal nail spacing at double top plates,band joists,and girders shall be a double row of 8d staggered at 3 inches on center per figures below:Vertical and Horizontal Nailing for Panel Attachment WEN THIS EDGE RMS ON FRWING USE8d NAILS - AT6'b c —--r== -- tl n / u u; N tl 11 11 I • .. 11 - 11 11 11 Il N li m itIlls ' 11 Q 11 If(.f 1 V it 19 m rl W fl 1 Z m - ll n 1 I It II 11 ofLr (aj 11 11.FW„ 1 19' 11 11it 11 11 -- . V McMSPACM t See Detail on Next Page Vertical and Horizontal Nailing for Panel Attachment ti AWC Guide to Wood Construction in Sigh end Areas:110 mph Wind Zone Massachusetts Checklist for Compliance(7so Cmn 5301.2.1.1)1 ► : d ; I ► i za I d II I� ► I , t FRAMING MEMBERS I EDGE M DIAIE ► ►I ► j--------- --- ---- ------- ----- �._ STAGGERED 3'MMI AWL PATTERN PANEL PANEL EDGE � DOUBLE MAIL EDGE SPAMGDML Detail Vertical and Horizontal Nailing for Panel Attachment ` AWC Guide to Wood Construction in High Wind Areas:110 inph Wind Zone Massachusetts Checklist for Compliance(7so CMsso1.2.1.1)1 FAQ*: WFCM Checklist Question: I understand if a new home is built in a town in a no mph wind zone then the American Forest and Paper Association (AF&PA) Wood Frame Construction Manual can be used to prescriptively design it. I also understand that in some cases the home can be framed per the WFCM 1oo mph Guide, if it meets certain requirements including but not limited to aspect ratio, roof height, number of stories, and exposure category (B). I have heard that Massachusetts has a "modified" checklist that can be used instead of the checklist at the end of the Guide. Is this true and what can you tell me about this "modified checklist? Answer: You are correct on the items that you have noted. MA has modified the checklist in several important ways. The MA version allows a roof with a pitch up to and including 8 in 12 to not be "counted" as a story. Further it does not require steel hold downs and straps in many locations if full height sheathing is used as defined in the MA checklist. Further, if the building will have furring strips installed in the ceiling abutting the gable wall then 2 x 4s installed on top of the ceiling joists are not required. There are other changes as well that were not noted here. The MA version of the checklist was formulated in recognition of the highly regarded framing methods used in MA for many years and wood framing that has. been used in North Carolina over the past 10 to 15 years which has performed well in severe hurricane weather in that state. *Answers to FAQs are opinions of the BBRS Staff and do not reflect official positions or code interpretations of the BBRS. • Town of Barnstable Regulatory Services Richard V.Scali,Director Building Division t � t Paul Roma,Building Commissioner. i639.. �� 200 Main Street, Hyannis,MA 02601 www.town.bamstablema.us Office: 508-862-4038 Fax: 508-790-6230 HOMEOWNER LICENSE EXEMPTION Please Print DATE: JOB LOCATION: rV floot Al 4PT 0 41,40.5 numb !GA/Ar V villag "FlolvlEowNER": �dTJ� t /C1 e 9 N e y name home phone# work phone# CURRENT MAILING ADDRESS: I Y 61A, �° ✓e - ity/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 y IN Person(s)who owns a parcel of land on which he/she resides or intends to reside,on which,there",`or is intended-to, _e,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. SigrAure 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. , ' H OWNER'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 lackof 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 this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit fonns\EXPRESS.doc 06/20/16 7 Town of Barnstable ti Regulatory Services MAW` a . ` Richard V.Sm1i,Director. 6 . Building Division. Paul Roma,Building Commissioner 200 Main Street,Hyannis,MA 02601 www.town.barnstable.ma.ns Office: 508-862-403 8 Fax: 508-790-6230 4. Property Owner;Must: Complete and Sign This Section If Using A Builder ,,, I ,as Owner of the subject property hereby authorize to act on my bebA in all matters relative to work authorized by this building permit application for: (Address of Job) I **Pool fences and alarms are the responsibility of the applicasit'Pools are not to be filled or utilized before, fence is installed and all final inspections are performed and accepted. Iz 5 Signature of Owner Signature of Applicant Print Name Print Name 7 Da Q:FORMS:OW NERPE VVMSIONPOOLS PETITION FOR INFORMAL Docket No. Commonwealth of Massachusetts ® PROBATE OF WILL The Trial Court ® APPOINTMENT OF PERSONAL Probate and Family Court REPRESENTATIVE PURSUANT TO G.L. c. 19013;§ 3-301 ® Original Form El Amended Form Estate of: Ruth Lillian Duchesney Barnstable Division First Name Middle Name Last Name Date of Death: 5/19/2017 I. GENERAL INFORMATION The Petitioner(s) (hereafter"Petitioner"), an interested person(s), makes the following statements: 1. Information about the Decedent: ' Name: Ruth Lillian Duchesney Age at death First Name Middle Name Last Name Also known as: Ruth L. Duchesney Name Street Address: 14 Paine Avenue Hyannis MA 02601 (Address) (Apt,Unit, No.,etc.) (City/Town) (State) (Zip) The Decedent was domiciled in Hyannis MA (City/Town) (State) FORM ALERT: A death certificate issued by a public officer is in the possession of the court or accompanies this Petition. 2. Information about the Petitioner(s): Name: Leonard L Duchesney, Jr. First Name M.l. Last Name 98 Kennesaw Avenue Centerville MA 02632 (Address) (Apt, Unit, No.etc.) (City/Town) (State) (Zip) Mailing Address, if different: (Address) (Apt,Unit, No.etc.) (City/Town) (State) (Zip) Primary Phone#: 508-775-1809 The Petitioner's interest in the estate is as follows (e.g., Personal Representative named in a will, surviving spouse, heir,. devisee, etc. See G.L. c 190B § 1-201(24)): Name: First Name M.I. Last Name r (Address) (Apt,Unit, No.etc.) (City/Town) (State) (Zip) Mailing Address, if different: (Address) (Apt,Unit, No.etc.) (City/Town) (State) (Zip) Primary Phone#: The Petitioner's interest in the estate is as follows (e.g., Personal Representative named in a will, surviving spouse, heir,. devisee, etc. See G.L. c 190B § 1-201(24)): 3. This Petition is filed within the time period permitted by law(See G. L. c. 1906,§3-108).Three years or less have passed since the Decedent's death, or the following circumstances authorize tardy proceedings(include statutory reference): MPC 150 (4/15/16) 1page 1 of 4 T-k-1 -,-icnm R4 a_n7)a-,. t FORM ALERT: Do not use this form to file a late probate proceeding pursuant to G. L. c. 190B, § 3-108(4). Use form MPC 161. 4. Venue for this proceeding is proper in this county because on the date of death, the Decedent: ® was domiciled in this county. ❑was not domiciled in Massachusetts, but had property located in this county at: (Address) (Apt,Unit,No.,etc.) (Cityrrown) (State) (Zip) S. ® The Petitioner gave written notice seven (7)days prior to petitioning for informal probate or appointment by sending a copy of this Petition and death certificate by certified mail to Division of Medical Assistance, Estate Recovery Unit, P.O. Box 15205, Worcester, MA 01615-0205. II. PERSONS INTERESTED IN THE ESTATE 6. The Decedent's surviving spouse, children, heirs at law and devisees (if any), so far as known or ascertainable with reasonable diligence by the Petitioner are as stated in form MPC 162 Surviving Spouse, Children. Heirs at Law AND if the Decedent died with a will, form MPC 163 Devisees incorporated herein. ❑ There are additional heirs at law who are not known to the Petitioner(Formal proceeding required). FORM ALERT: Failure to submit this information will result in a delay in processing your case. III.TESTACY STATUS 7. The Decedent died (select one): ❑ Intestate(without a will) After the.exercise of reasonable diligence, the Petitioner is unaware of any unrevoked testamentary instrument relating to property in Massachusetts, or ❑ see attached statement of why such an instrument is not being probated: ® Testate(with a will) The date of the Decedent's last will is 1/11/1973 ® The dates of all codicils are 8/28/1996 (select one of the following): ® The original will is in the possession of the court or accompanies this Petition. ❑ The original will has been probated in Massachusetts and the Petitioner adopts the statements in the Petition for Probate. ❑ The original will has been probated in the state or country of An authenticated copy of the will and proof of its probate are filed with this Petition. The will and any codicils are referred to as the will. The Petitioner, to the best of his or her.knowledge, believes the will was validly executed. After the exercise of reasonable diligence, the Petitioner is unaware of any instrument revoking the will and believes that the will is the decedent's last will. IV. APPOINTMENT OF PERSONAL REPRESENTATIVE (if requested) 8. ❑ The Petitioner requests that the following qualified person, who is 18 years of age or older, be appointed Personal Representative: ® Self only. ❑ Self and other(s): ❑ Other(s): Name of other(s): First Name M.1. Last Name (Address) (Apt,Unit, No.etc.) (Cityrrown) (State) (Zip) Mailing Address, if different: (Address) (Apt,Unit,No.etc.) (Cityrrown) (State) (Zip) Primary Phone#: MPC 150 (4/15/16) page 2 of 4 7'.. 6-1 ..... /0AM C40 077C n w 4 9. All nominees listed above have priority for appointment: ® by statute. See G. L. c. 190B, § 3-203. ❑ by renunciation and/or nomination. Persons with higher or equal rights to appointment are: First Name M.I. Last Name FORM ALERT: All required renunciations/nominations using form MPC 455 must accompany this Petition. 10. Select one of the following: ® No court has appointed a Personal Representative and no such appointment proceeding is pending in Massachusetts or elsewhere. ❑ A court has appointed Personal Representative, whose appointment has not been terminated, or an appointment proceeding is pending in the State of and the Personal Representative's name and address is: Leonard L Duchesney, Jr. First Name M.I. Last Name 98 Kennesaw Avenue Centerville MA 02632 (Address) (Apt,Unit,No.etc.) (Cityrrown) (State) (Zip) 11. Select one of the following: ❑ A bond with sureties with the penal sum amount of$ has been filed. ® A bond without sureties has been filed and is,permissible because: ® The will waives sureties on the bond and no interested person has demanded that a bond with sureties be filed. ® All devisees(if a will is filed) or heirs(if no will is filed) have waived sureties in writing using form MPC 455 and all the waivers are filed with this Petition or are in the possession of the court. FORM ALERT: All persons seeking appointment must file a bond using form MPC 801. V. RELIEF REQUESTED Wherefore,the Petitioner requests that the courtimagistrate: ® Admit the Decedent's will to informal probate. ® Appoint the nominee(s)with priority for appointment as Personal Representative of the estate in an unsupervised administration to serve ❑ without ❑ with sureties on the bond and that Letters be issued. SIGNED UNDER THE PENALTIES OF PERJURY I certify under the penalties of perjury that the foregoing statements are true to the best of my knowledge and belief. Date: Signature of Petitioner Date: Signature of Co-Petitioner(If applicable) Information on Attorney for Petitioner, if any Signature of Attorney James R. Mac Neill (Print name) 3010 Main Street (Address) (Apt,Unit,No.etc) Barnstable MA 02630 (CityrTown) (State) (Zip) Primary Phone#: 508-362-1121 MPC 150 (4/15/16) �. page 3 of 4 TwhoLaw=(800)518-8726—c.a.f. B.B.O. # 312220 Email; Macfitchjrm@aol.com a MPC 150 (4/15/16) page 4 "of 4 •- Ti.,K I ow_/AM1 F1 A_A79R_r n f 77--i-�- ---?---! --�-1'- t —1---{---t---� {r----, r--i----,-----�-----i---{-1— I , _i_�r._._� I — �+_ �e�.` , N �—I. I �—— F_ wi yso AL 77 _17 OWLY -� { . - -� , - i - i ! ! i i '�`r5 I ' i- i i _i i �.i p _-�-I-+ -�- � _�_I _I _ '-_L._!_._ � ( # ; j-1--i=;-) i I i 1 ! �---� I=!�-_.I � I I f.� i f i _.i __i _I___ i j� �i-.i I I i I � l ( i � � + i i �---I�-.1 + � I I I '--i nj The Corr momvealth of-Vassadrusefts Department o}'ludushiat Acdden& r Office o,f 1mw*afions . . 6,jfJ0 Wasbingfon Street- __ Boston,MA 02111 wwvw massgvFM i Workers' Camipensafion Iusurance Affidavit:Btdlderm/CnntracturslFI cians/Phumbers ApplicantInfQrmation ease Print Na= C.ty S ref r' Phones �- Are you an employer?Check the appropriate box: Type of project{retlnired}: 4_ l am a contmetDr and I � I.❑ I am a employes veitb. � �A general . employees(full andlor part-time)-* ]save hired the sub-contractors, 6. ❑New oonsfituctian . . 2.❑ I am a sale prapdetar orpartuer- listed on the attached sheet: 7-,( emodeliug ship and have no employees These sib-cossrractors have g •Q Demolition w Hng for me in my capacity. employew and have wodaus' ivarlaecs'. cfluig, �crtra„re � camp_insuragm$ 1� 9. El Budding adxlitiaa jNo 5. ❑ We are a corporation and its El Electrical repairs or a ddstioas required-] i 3.Ell am a homeowner doing all work officers have exercised their 1L❑Plumbing repairs or additions myself- o wcxileers' xigld of exemption per MGL insurance rued.]f mil} c.152,§l(4�and we have no 17 El Roofrepaius employees.[Now 13.❑other comp-insurance j •E�ay appFic B�ac checks box ffl—elso fM oit the section below dwwing dmk wode'le compeasaS policyinfim=aM ameovfners wlm submit fts afhdmw inficatinS they as chino zH wo*and flea hire aats0e cry„tracmrs mast submit a new affidzeft huhca3mp such. fCauuac=Azt cliecic idds bmr must sttachs3 m addIbamat shag sboumg the name of the sub-caWnrtom and state Whether or not these eatities hsee emphryees.Ifthesnb-ccm-actntshave emplapees;dwymustgmvidetheir wM*M'gyp.pGrMY z mabm I am an errrpJny�er that isprmzrIiitg tvarkers'cattrperesrah�rr insrirarrce for ez}s enrploj�ees �'eT�iav is fiiep�vFicy�and jQb site informadon. Insurance Company Name: Policy or pelf-ins Lic. FxpiradonDate: Job Site Addre= CiLy/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 MOL c 152 c-an lead to the imposition of criminal pena% s of a fine up to$1,Sdt}_OD and/'or one-yearimprisonmenk as well as civil peaalties.in the form of a STOP WORK ORDER and a one of up to ll_tl.0 a day against the violator. Be advised that a copy of this statement may.be fi rimded to the Office of 1mvestrgations ofthe DIA.for insurance coverage verification_ I do hereby c&16 ustder the pains ands pehafites afpadury that Aa infbrmafiorrptmirted abmre is bare acid carrect bate �'. f , Phone it Ojokiai use and. Do not wrke in tlds area,tic be catnpieted by city ortotva o fjreirit City or Town.: PermcitUcense# Issuing-A-utheiity[circle ogre]: L Board of Health 2.Building Department 3.Cltyyrown Clerk 4.Electrical Inxpector S.Plumbing Inspector 6.Other Contact Person' Phone#• __ I ormation and Instructions ]V�ze.c hmetts GeberalLaws chapter I52 rues all employers to provide wows'compensation forfhea cnapioyees. P0rSa=&t D this sf�e,an e�Toyw is defined as.":every person in the service of another under ally contract of hire, empress or fugalied,oral or wry" AIL e27Vroyer is defined as"an indiviaaal,pmInership,association,corpora ffon or other legal entity,or any two or more of the foregoing engaged is a Joint eoimprise,and mdlnding the legal representatives of a deceased employer,or the receiver or t WteM of an mdividaal,pattnMMhap,association Or other Iega1 entity,employing employees However the owner of a dwelling horse having not more ihEm 11=apartments and who resides therein,or tine occupant of the - dwelling house of another who employs persons to do maintenzace,construction or repair wont on such dweIIing house or on the grounds or budding appur E themto shall notbwanse of such employment be deemed to be an employer." MGL daaptnr 152,§25C(e7 also sites that"every state or local licensing agency shall withhold•Hie issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for airy applicant:who has not produced acceptable evidence,of cumpIian—with the Insurance.coverage required.-" Additionally.MGL chapter 152,§25CC7)slates aNefther the commonwealth nor nay of its political subdivisions shall EM into any contract for the pPrfoma—*'m ofpubho work uajil acceptable evidence of compligace with the insurance, reTnrements:of this chapter have been presented to the contracting authority-" Applicasrfs , Please f DI out the workers'compensation affidavit completely,by checking the boxes that apply to yore situation and,if necessary,supply sob-contractni(s)nam e(s), add=s(es)and phone mlmber(s)along with their certificate(s)of msm-ance. Limited Liability Companies(LLC)or Limited Liability-Pminersbips(LIT)with no employees other than the members or para=s,are not mquired to casy workers'compensation msoranof_ If an LLC or LLP does have employees,a policy is rmpired. B e advised that this affidayit may be submitted to the Department of Industrial Accidents.mr confnmaiion of msuumce coverage. Also be sure to sign and date the affidavit The affidavit should be mtnmexi to the city or town that the application for the permit or license is being requested;not the Depmtneaf of Industrial Accidents. Shouldyou have any questions regarding the Law or ifyou are regmired to obtain a workers' compensation policy,please call the Department atthenumber listed below- Self-rosinedcompardesshould enter rhea self-irsormce Iicerse number an the appropriate line: City or Town Officials t - Please be sore that the affidavit is complete and pried-Iegiibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Iavesi;gations has to contact you regarding the applicant Pleas a be sure,to fill in the peamitllicrose number which will be used as a reference number. In addition,an-applicant that must submit multiple pmmjt icause applications in.any given year,need.only submit one affidavit indicaiiag cmirzt. policy information(if necessary)and under"Job Site Address"the applicant should write,"all locations in (may 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 proofthat a valid affidavit is on file for f�e'pem#3 or licenses A new affidavitmust be filled.out each year.'Where a homeowner or citizen is obtammg a license or pezmit not=Iated to any business or commm-vial ventim (i-e. a dog license or permit to bran leaves etc-)said person is NOT reTii�to complete this affidavit The Office of Inv e,sti g a ti.on. would Lake tr:thank you i a 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 faznumber_ Thy CauM:kan ttbE of Massachmcns • DegarFmtnfi cif lad A�i3�nts offf=of ft-VM6 ntio= �R4�ashmgtau B MA 0�111 T6L#617-727-4900 cmt 4€6 W 1-9 MA SSA Fax-617`27 7M Kevised 4-24-t)7 p q-m gagidia f Town of Barnstable Regulatory Services dGtKE Richard V.Scali,Director. Building Division RAMO BM IF Paul Roma,Building Commissioner MASS. 1639." 200 Main Street, Hyannis,MA 02601 www.town.barnstable.ma.us } Office: 508-862403 8 Fax: 508-790-6230. HOMEOWNER LICENSE EXEMPTION Please Print DATE:�I 7 0 yafs JOB LOCATION: l • / {�e �U2 number street village "HOMEOWNER": / : name home phone# work phone# . CURRENT MAILING ADDRESS: cityhown 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 Qerformed 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 t 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." R 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 r 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 this issue is a form currently used by several towns. You may care to amend and adopt such a form/certification for use in your community. Q:\WPFILES\FORMS\building permit forms\EXPRESS.doc 06/20/16 r Town of Barnstable Regulatory Services EARMARILAM ' ` Richard V.Scali,Director. " Building Division. Panl Roma,Building Commissioner 200.Main Street',Hyannis,MA 02601 www.town.barnstable.ma.us Office: 508-862-4038 Fax: 5.08-790-6230 Pr perty Owner M Complet and Sign T Section If A B der as Owner of the subject property hereby authorize to act on my behalf in all matters relative to work thorized by this b ling petmit application for. (Address of Job) **Pool fences d alarms are the responsibility o the applicant Pools are not to filled or utilized befort fence is ins ed and all final ins ectio are performed and accepted. P P P Signature of Owner Signature of Applican Print Name Print Natne Date Q:FORMS:OWNE"ERMISSIONPOOLS AC® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/D8iiY8)17 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: JIM HINDMAN Schlegel & Schlegel Ins Broker PHONE FAX 34 Main Street E-MC.AIL ' (508) 771-8381 A/ No; (508) 771-0663 ADDRESS: schlegelinsurance@qmail.com West Yarmouth, MA 02673 INSURE S AFFORDING COVERAGE NAIC# INSURER A:AM GUARD INS URED INSURER B: JASON W WILSON INSURER C 331 BUCKSKIN PATH INSURER D: CENTERVILLE, MA 02632 INSURERS: 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. INSR _._, .. - ---- - ------ ----- LICY--EFF-----POLICY--------ADDL SUBR PO EXP LTR TYPE OF INSURANCE INSR WVD POUCY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED PREMISES a occurrence) $ CLAIMS-MADE OCCUR ME EXP(Anyone person) $ PERSONAL&ADVINJURY $ GENERAL AGGREGATE $ GEN'LAGGREGATE LIMITAPPLIES PER PRODUCT'S-COMP/OPAGG $ POLICY PRO JECT LOC $ AUTOMOBILE LIABILITY COMB INEDSINGLELIMIT Ea accident $ ANYAUTO BODILY INJURY(Per person) $ ALLOWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIREDAUTOS NON-OWNED PROPERTY DAMAGE _ AUTOS Per accident $ $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS MADEAGGREGATE $ DED RETENTION$ $ A WORKERS COMPENSATION WC-WCBAM000114930 4/19/17 4/19/18 WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N ANY PROPRIETOR/PARTNER/EX-11— I PR OFFICER/MEMBEREXCLUDED? N/A E.L.EACH ACCIDENT $ 100,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes•describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101 Additional Remarks Schedule,if more space is regui red) JASON W WILSON HAS ELECTED NOT TO BE COVERED UNDER HIS CURRENT WORKERS COMPENSATION POLICY CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN TOWN OF BARNSTABLE ACCORDANCE WITH THE POLICY PROVISIONS. BUILDING DEPARTMENT C/O JEFFREY LAUZON AUTHORIZED RESE 200 MAIN STREET IHYANNIS MA 02601 ©1988-20 10 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Phone: (508) 862-4038 Fax: (508) 790-6230 E-Mail: JEFFREY.LAUZON@TOWNOFBARNSTABLE.MA.US