HomeMy WebLinkAbout0024 POTTER AVENUE Amo
Town of Barnstable *Permit
�0 Expires 6 mon�(s m' �e dore
` Regulatory Services Fee
i nsRNC1`1AiyF„ s
0"9' Richard V.Scali,Director
Building Division
Tom Perry,CBO,Building Commissioner
200 Main Street,Hyannis,MA 02601
www.town.barnstable.ma us
Office: 508-862-4038 Fax: 508-790-6230
EXPRESS PERAUT APPLICATION - RESIDENTIAL ONLY
2V Not Valid without Red X--Press Imprint
Map/parcel Number)
Property Address1'2` �C?;77G/ � �1i,��/S /�� �26��
❑Residential Value of Work$ Minimum fee of$35.00 for work under$6000.00
Owner's Name&Address
Contractor's Name_ /fielephone Number
Home Improvement Contractor License#(if applicable) Email:
Construction Supervisor's License#(if applicable)
❑Workman's Compensation Insurance ® c
Check one: p
❑_ -am a sole proprietor APR 22 I-am the Homeowner
C7- 2016
❑ I have Worker's Compensation Insurance 1 T Q wN OF
AC A R N n'�T ""L�R C
Insurance Company Name
Workman's Comp.Policy#
Copy of Insurance Compliance Certificate must accompany each permit.
Permit Req st(check box)
c:9—Re-Toof-(hurricane nailed)(stripping old shingles) All construction debris will betaken to
❑Re-roof(hurricane nailed)(not stripping. Going over existing layers of roof)
❑ Re-side '
❑ Replacement Windows/doors/sliders.U-Value (maximum.32)#of windows
#of doors:
❑ Smoke/Carbon Monoxide detectors 4'floor plans marked with red S and inspections required.
Separate Electrical&Fire Permits required.
*Where required: Issuance of this permit does not exempt compliance with other town department regulations,i.e.Historic,Conservation,etc.
***Note: Property Owner must sign Property Owner Letter of Permission.
A copy of the Home Improvement Contractors License&Constrpction Supervisors License is
required.
(SIGNATURE:
;QAWPFILES\FO -' \ `d_ing permit fonm\EXPRESS.doc
Revised 040215
27m Camromveah*qfA&rsachaseft
D'eparbneut o,f&dustiid Acdde?ds
office af'.£i"V144atiom
600 Washington&reet
Boston,MA 021-11
immmasLgorldia
Worlmrs' Campensaficin Insurance Af ficiavit:Bmide7dCflntr=WrsMectdcian&iplum2bers
Applicant Inf an /' Please Print F "biv
bw, a phone
Are YoIIlan rmployer?Check the approprla a bares Type of project(required):
I_❑ I am a employ with 4_ ❑I am a general contractor and I'
6
* have hired the sub-contractors . 0 New cros�cticn
employees(fall aradlar par�time�. .
2.❑ I am a sole proPprietor orpartner listed onthe attached sheet 7_ []Rem deling
and have no 1 ees These sub-coadractom have
�P �P� & ❑Demolitiaa
marking for me id anycapacity- employees andbnre Wodb=,
[No 'camp.insurance comp_4i1�*•�,,—.1 9_.❑Budding addition
i 1 5. ❑ re We a a-emporafiia and its M❑Electrical repairs or a,dcSfions
�/ officers have e=-ised their
y
t 3.__ I-am a bomeorumer doing all work 11-O Plumblagrepaim or addidans
— t f-[No woxk='comp- rim of emempfion per MGL L. Roof repairs
+nstrance regmred j i c.152,§1(4k and we have no
employees- workers' 13-❑Other
cord iamnance required_)
*Aayapptic—td=tcberksboxfl— also fiIIovflhesectoab99wsbmvagdmiwwaiters'c0=pM RtiCMP0&Tia5emsaae
#�amevaraecswba sait�t dvs>�dat inratiag they are daia�sIFwaaY sud B�l�xe autsi3er,.nr.4ren.cTmG}sv�mitanemaiadaait Iadi sack_
TCaatectars tta1 r-1mc r 1hft box mast rftr'h�ffi addili�al s3neet shoRiag thensme of the S4 ca�sr�a mmd stafe�rhethB arnot those a ham
=Pbyees.Ifthe5Vb-caata2asI=e eapiayeas,the}'musrpmride their warken'comp.pahU nsanbm
i
I a�n an svtpr flrttis piauidurg workers'ca�perestiirrrr iuszirattce�vr�3'emP�3'eex Setory is#JrR ptrlicy aril ja2r site r ,
information.
Insumace Company Name:
'Policy 4.,'or Self--ins.l ic-4- FxpirationDate:.
Job Site AAdress; CitylStatelytp:
Attach acopy of the work-ere comripensationpolfcy declaratian page(showing the policy,=mber and expiration date).
Failure to semen coverage as requirerlunderSe-ction 25A o€MGL c- 157-can lead to the imposition of criminal penalties of a
fine up to$U.00_OD andror one-year imprisonment as will as civil penalties in i ie form of a STOP WORK ORDER and a Em
of up to 0.00 a day against ffie violator. Be adidsed that a copy of this sfateme t reap be forwarded to the Of rice of
lmvestFgations of he DIA for irtsmmm coverage verification.
I do uer by comfy under da pains and panabVes afFedkq Hutt the igjbraza#iars pM i&d alE m e is hats and correct
D szrge,�,—C,
phone- ?2
t3,�al use ari£�. �Da riot o-�rite in tlr�area,Hri 5e crrtnpleted by testy arten�r a,;€j`ictaL .-
Cdy or Town: .rt-. Fermiib;tense;g
Issuing Aslthority(circle floe):
L Board of wealth 2.llmIling Department 3.Cityffown Clerk 4.Electrical Inspector S.Plumbing Inspector
b.Other
L'ontact Person Phone ih
ormation. and lastracions
0 ID Wad'compensation for fbeg employees_
M�cc�r_�ncefLs Geheral Laws chaps I52 requires emPlvyets Fsavide
parsaa&to this side,an..=T&yee is defined as."-.evmy person in f ac service of der mder any cmtmo t ofbae,
express or implies oral or wrhtea."
An.employer is defined as"an indzvid ag pmtaersbip,associado33,ccxpmzf=or other legal entity,or any two or more
of the foregoing is a joint ente tprlse3,and inchidmg the legal s P=Mtdives of a.deceased employes,ar the
receiver or t mstee of an mffividnal,Partnership,association or othCrlegal entity,employing employees' However the
ovynex of a dwelling horse ha-Y.mg•not more tiu.three aPartments and vvho resides therein,or the occopaat ofthe -
dwelling house of anofer who employs persons tD do made,canstru�on or repair wow on such dwelIlmg h=D
therein sballnotbecamr,of snrh employmesrfbe deemedto be an employer_"
or on the grounds or building aPgratEnaz¢ � .
MGL cbapter 152,§25C(6)also sums that"every sfa:L-or IocaI licensing agency shall withhold$ie issuance or
renewal of a Hcense or permit to operate a baseness or to construct buRdings in the comm.onwwlth for any
mpplicantvvho bas notproduced acceptable.evidence of compliance with the ias-urance coYexageregoire�"
Additionally,Ma,cbaptes 152, §25C(7)stairs-Neither the caoamcmweabh nor guy ofits poEdcal subdivisions shall
e into any contiart for the performance ofpnblic W013Cmiff acceptable evidence of compliance with the insm-mce._
req=em:=is of this chapter have been pre$enird to the CODt- �aizthoity_"
APPaczn-b
Please fill oht the worb='compensation affidavit completely,by checl®.g the boxes that apply to your situation and,if
necessary,supply sib-mutzctor(s)namp(s), addre'ss(es)andphonenumber(s) alongwithiheir=tda—cat*) of
insmance. Limited Liability Comparries(LLC)or Limited Liabi7rty Partnerships(LLP)wrthno employees other thaw the
members or partoen's,ate not regoaed to cant'wcdcm-e compensation ins r ce- If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be snbmittd to the Department of Indnsfrial
covera
Accidents for conFrmation of ice ge: Also Be sure to sigh and.date the affidaviE The a$davit should
be retnmmed to the city or tDwn that the application for the permit or license is being requested,not the DePazimeait of
T xIast-i T Accidealts. Shouldyou have any questions regarding the law or ifyou are regan-ed to obtain a worlo rs'
connp=sajionpolicy,pleasecalltIm'Departmen±atfi2enumberlistedbelow Self-fimred companies should entrrthtir
self-msmr-aace license nBmber on the appropriair line.
City or Town Offidals .
t -
Plmse be see that the affidavit is complete and pried legibly. The Departmeathas provided a space at the botirua
ofthe affidavit for you to fM out in the event the Office ofInvestigations has to coactyouregardingthe applicant-
Please be sure to fill in the permit/Iiceuse rnanber which will Be used as a rcfrrenoe nomber. In addition,an applicant
that must submit muh pie p=WHcense applications in any given year,need only submit one affidavit indicafmg ctm'ent
p oIi cy infosuation(if necessary)and under"Job Sb,- Tress"the applicant should write"all locations>n (may ar
town)."A copy of the-affidavit that has been officially stamped or marked by the city or tovm may be provided to the .
applicant as proofthat a valid affidavit is on file for frzfnre permits or licenses A new affidavitmust be fMcd.oirt each
year.Where a home owner or citizen is obtaining a liceose or pftTm not related in any business or commercial ventise .
Cl-e_ a dog license or pe nit in bum IeaM eta.)said person is NOT rega rd to complete this affidavit
The Office of Investigations world 15e to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give=a call
The Departmenf s address,telephone and fax n=ber
Depadment cuff Ix dial AOC eats
Office Of f ve&tk. Ati=
BwWus MA 0�1 I I
TeL 617-' -49Q0 Qit 4-06 or 1-M-M 5SAFF,
Fax 9 617-727 M
Revised4-24-07 ��a
MASS
Town of Barnstable
Regulatory Services
Richard V.Scali,Director
Building Division
Thomas Perry,CBO
Building Commissioner
200 Main Street, Hyannis,MA 02601
www.town.banistablema.us.
Office: 508-862-4038 Fax: 508-790-6230
Property Owner Must
Complete and'Sign This Section
.If using A Builder
as Owner of the subject property
hereby authorize to act on tny b
in all matters relative to work authorized by this buildingp�'t application for:
•
(Address of Job)
Signature of Owner Date
Print Name
If Property Owner is applying for permit,please complete the Homeowners License Exemption Form on the
reverse side.
QAWPFaXSIFORMS\buildmgpermit forms\EXPRESS.doc
Revised w215
Town of Barnstable
Regulatory Services
rojy Richard V.Scali,Director
ti
Building Division
* BMxsrwst.E, « Tom Perry;Building Commissioner
MA
163FF�+� 200 Main Street; Hyannis,MA 02601
www.town.barnstable.ma.ns
Office: 508-862-4038 Fax: 508-790-6230
HOMEOWNER LICENSE EREWTION
Please Print .
CDATE:� .
JOB IACATION:
number-,.--.n street �.��- -•.. '`village
LtROl�'iL0�� �,�+
1'P19G1\n. '
home,phone-# work phone# .
CURRENT LMARINGG ADDRESS:�ATe
l`f city/town-- �s tate_..,..,.-..
The current exemption for"homeowners"was extended to include owner.-oc- ied`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 ear 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 shall be reMonsible for all such work performed under the building all such work performed under the buildingpermit. (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 d that he/she will comply with said procedures and requirements.
Approval ofBuildmg Official
Note: Three-family dwellings containing 35,000 cubic feet or larger will be required to comply with the State Building Code
Section 127.0 Construction Control
HOMEOWNER'S EXEMPTION
The Code states that:'Any homeowner performing work for which a building permit is required shall be exempt
from the provisions of this section(Section 109.1.1-Licensing of construction Supervisors); provided that if the homeowner
engages a person(s)for hire to do such work,that such Homeowner shall act as supervisor."
Many homeowners who use this exemption are unaware that they are assuming the responsibilities of a supervisor
(see Appendix Q,Rules &Regulations for Licensing Construction Supervisors,Section 2.15) This lack of awareness often
results in serious problems,particularly when the homeowner hires unlicensed persons. In this case,our Board cannot
proceed against the unlicensed person as it would with a licensed Supervisor. The homeowner acting as Supervisor is
ultimately responsible. .
To ensure that the homeowner is fully aware of his/her responsibilities,many communities require,as part of the
permit application,that the homeowner certify that he/she understands the responsibilities of a Supervisor. On the last page
of this issue is a form currently used by several towns. You may care t amend and adopt such a form/certification for use in
your community.
QAWPFIIMT0RMS\buiding permit forms\EXPRESS.doe
Revised 0402is
14L
TOWN OF BARNSTABLE BUILDING PERMIT APPLICATION
O i Ol ��
Map Parcel Application #
Health Division Date Issued /0'z�✓`f�
Conservation Division Application Fee
Planning Dept. Permit Fee
Date Definitive Plan Approved by Planning Board
Historic - OKH _ Preservation / Hyannis
Project Street Address Oe
Village Z//
Owner /�/2/S�/�/�t/G'��� Address5� ,
Telephone; 9 a?D,3' :2
Permit Request `, �?.��Yeoee /9 i�v ��2 9`��� /�,X_44i�� ��a,�B
Square feet: 1 st floor: existing proposed 2nd floor: existing proposed Total new
Zoning District Flood Plain Groundwater Overlay
Project Valuation j Construction Type /VY 7-1d�l
Lot Size Grandfathered: ❑Yes ❑ No If yes, attach supporting documentation.
Dwelling Type: Single Family A Two Family ❑ Multi-Family (# units)
Age of Existing Structure Historic House: ❑Yes A No On Old Kind' ighway2J Y(�?_ g(No
Basement Type: ❑ Full ❑ Crawl ❑Walkout ❑ Other w
Basement Finished Area(sq.ft.) Basement Unfinished Area (sq.ft) C)
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 ❑ No . If yes, site plan review#
Current-Use.- ____-_ - __ _ -Proposed-Use
APPLICANT INFORMATION
(BUILDER OR HOMEOWNER)
Name ' �� � � � Telephone Number ���� �7��i—7/ 'f—
Address/ 9�2��� �:�2 License #
r i
i Home Improvement Contractor# /-t) y
Worker's Compensation #
r
ALL CONSTRUCTION DEBRIS RESULTING FROM THIS PROJECT WILL BE TAKEN TO
SIGNATURE f DATE /® 2b, f
FOR OFFICIAL USE ONLY
PPLICATION#
ATE ISSUED
MAP/PARCEL NO.
ADDRESS VILLAGE
OWNER
DATE OF INSPECTION:
j r=FOUNDA=TIC?N���w -....xwu f- .�r •:
FRAME
FIREPLACE
ELECTRICAL: .- ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: ROUGH FINAL
FINAL BUILDING'
DATE CLOSED OUT
ASSOCIATION PLAN NO.
lfte Commonwealth of Massachusetts
Department of Industrial Accidents x
Office of Investigations
600 Washington Street
Boston, MA 02111
'www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contrac"tors/Electricians/Plumbers
_Applicant Information Please Print Legibly
Name (Business/Organizadon/Individual):
Address:
City/State/Zi Phone#:Are you an employer? Check the appropriate box: '
1.� I am a employer with -f 4. ❑ I am a general contractor and I Type of project(required); '
employees (full and/or part-time).* have hired-the sub-contractors . 6• ❑New construction f
2.❑ 1 am a sole proprietor or partner- `listed on the attached sheet, 7.,-❑ Remodeling
ship and have no employees w These sub-contractors have g I Demolition
working for me in 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 doing all work officers have exercised their 11.❑ Plumbing repairs or additions
Myself. [No workers' comp. right of exemption per MGL
insurance required.] t a 152, §1(4), and we have no 12•❑ Roof repairs
3a.❑ I am a homeowner acting as a employees. 13.0 Other/,-/�,��/�AA t/
general contractor(refer to#4) - [No workers'
comp.insurance required,].-
*Any applicant that cbecks box#1 must also fill out the section below showing their workers'coazpcnsaaoz#policy infocm8aon.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside connectors must submit a new affidavit indicating such, t
tContracton 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 olic number.
I am an employer that is providing workers'compensation insurance
information. jor my employees. Below isthe policy and job site
'Insurance Company Name:
Policy#or Self-ins. Lic.#: Expiration Date:_ '/
Job Site Address: ��ij /7-. y� 4 City/State/Zip: JQ O TiGe,�
I Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).`
I Failure to secure coverage as required under Section 25A of MGL e. 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 u!�W the pains and penalties of perjury that the information_provided above is true and correct
Date:
Phone#
Official use only. Do not write in this area, to be completed by city or town official
City or Town: PermitfLicense#
Issuing Authority (circle one):
L Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector,5. Plumbing Inspector
6. Other
Contact Person: Phone#:
I
CAPECOD•27 KLIGETT
..,. CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY)
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFE I L 6(1312014
RS NO RIGHTS UPON THE CERTIFICATE HOLDER,THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR'NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER,
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed, If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy, certain policies may require an endorsement, A statement on this certificate does not confer rights to the
certificate holder In Ileu of such endorsement(s),
:OOVCER CONTACT
rgers&Gray Insurance Agency, Inc, NAlor: Barbara DeLawrence .
4 RtB 134 FA)z__
�- 877� 816.2156 _
-uth Dennis,MA 02560 . r-M E bdelawrence Droqersgray.com
INSURERS AFFORDING COVERAGE NAIC N
_ ... ..._..__..._..___:__.__.._ " INSURER A;Peerless Insurance Company
R D INSURER 8:COMMERCE INSURANCE COMPANY
( Cape Cod Insulation Inc INSURER 0:Evanston Insurance Company
18 Reardon Circle INSURERD;ATLANTIC CHARTER INSURANCE GROUPR
South Yarmouth, MA 02664
INSURER E;
INSURER F;
ERAGES CERTIFICATE NUMBER: REVISION NUMBER:
r IS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
I DIICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
R;TIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
C USIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY-HAVE BEEN REDUCED BY PAID CLAIMS.-
TYPE OF INSURANCE POLICY NUMBER MMIDD FF POLICyyi Y EXP YYYYI LIMITS
X COMMERCIAL GENERAL LIABILITY
I EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE lX� OCCUR CBP8263063 04101/2014 04/01.12015
PREMISES(Ea occurrence) $ 100,000
MED EXP(Anyone person) $_ 61000
PERSONAL&ADV INJURY $ 1,000,000
G N'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
t_.J
POLICY PRO-
L_..1 JECT LOC
PRODUCTS_COMPIOP OTHER AGG $ 2,000,000
AUTOMOBILE LIABILITY COMBINE SINGLE LIMIT
T E acci e 1 $ 11000,000
ANY AUTO 14MMBCKVMK 04101/2014 04/01/2015 1 ALL OWNED X SCHEDULED BODILY INJURY(Per parson) $
AUTOS AUTOS BODILY INJU (Par accidanl) $
HIRED AUTOS X Al T SEEDON0 RYPROPERTY OAMAGE__ —"—
Per acoide I $
X UMBRELLA LIAR X OCCUR $ —
EXCESS LIAR a
EACH OCCURRENCE $ 11000,000
_ CLAWS-MADE XONJ453514 04/01/2014 04/0112016 AGGREGATE $
CEO X RETENTION 10,000 A gre ate T 000
WORKERS COMPENSATION g $ 1,000,
ANp EMPLOYERS'LIABILITY PTA TE RRH•
OFFICERIMEMB RIEXCLUDED?ECUTIVE Y� NIA WCA00626904 0613012014 06130/2015 E.L.EACH ACCIDENT $ 1,000,000
(Mdnddlory In NH)and E.L.DISEASE•EA EMPLOYEE $ 11000,000
III yes,describe under '
OESCPoPTION OF OPERATIONS below E.L.DISEASE•POLICY LIMIT $ 11000,000
1 I
gRIP?ION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Addlllonal Remarks Schedule,may be ehached If more apace Is required)
kart;Compensation Includes Officers or Proprietors,
I to al Insured status Is provided under the General.Liability and Auto Liability when required by written contract or agreement with the Certificate Holder.
i ,
r I I
Massachusetts -Depat'tm,ont of Public Safety
ard of Building Regula;fons •nd Standar_cis
Cowniction supurvisor
License: CS-100988'
°.r
k.[1..NRY.E CASS11�l
8 SHED ROW
WEST YARMOU1111
Expiration
Commissioner 11/1112018
a r
C- � E, �(>cz�f'(/yyLGLYIrG(12GrL�L a.p
Office of Consumer,Affairs and Business Regulation
10 Park Plaza Suite 5170
Boston, MassachLisetts 02116
I10me Improvt✓nient CQA�raOor Registration
Registration; 153507
- ,•;-.t# ^ ,, ��, i Type: larivafe Corporation
'n+•f 1 :...: Expiration: '12/15/2a14 l'111. 233831
CAPE COD INSULATION, INC
HENRY CASSIDY _ _._................ .. ......... -
18 REARDON CIRCLE
SO. YARMOUTH, MA 02664 r ,' ---. __.. ............
IN
Updato Address na(I rotui'n card, Murlc rats an Jo I,chlingc,
�. (a Address ]z1leuewnl Ej limploytnent ImtCardT
'ilr,�f(+f4��6l�r.u�l•lIHCT•(l/'G c��(�-(�CllrlJttGiFlGJlit�3 ' '� - � ., -
urricc orL'ensunnu'AfYnirs Ilusiness ttaguluribu "License or registration valid for individul'uso only
` before the ax�iratlon data. It'faun(I return to;
:a OME IMPROVEMENT CONTRACTOR' I
egistration: 15:3�67 Type;« Office of Consumer Affairs and Business Robulution .
xpiration: 12/1'5/2014 Private Corporation 10 Pai1(Plazii-Suite 5.170
'Boston,MA 02116
(OD INSULAI•IQNl,li�Ci
Y CASSIDY
A'DON CIRCLE !
NIOUITI,MA 02664 Undo seeretnry of vat' �witho t not re
OWNER AUTHORIZATION FORM
}
,(Owner's'Name) _
owner of the property located at
(Property,Address)
y s z t
(Property Address) '
hereby authorize
(Sub c )
.an authorized subcontractor for RISE.Engineering, to act on'my behalf to obtain a building
permit and to perform work on my property.
Ow igriature
Date ;
r
Assessor's Office Ost floor Ma Lot �'C�P' �^"p�� Permit#
'Conservation Office Oth floor i�" �1 - flues Date Issued-
Board of Health Ord floor '
Engineering Dept. Ord floor House# ez
Planning Dent. (1st floor/School Admin.Bldg.): tit
Definitive Plan A ved b Plannin Board 19
(Applications r ss : 0-9:30 a.m.& 1:00-2:00 .m.
TOWN OF BARNSTABLE
Building Permit Application
Protect Street Address `^
Village - > Fire District
(hvncr Da �t`� 'ti'A k Address
Telephone -2 2,9-+ C, V
Pe it Re guest: 1`
VL -g- F- � � I
Zoning District Flood Plain Water Protection
Lot Size Grandfathered
Zoning Board of ApMls Authorization Recorded
Current Use Proppsed Use q
Construction T i' �'-Crvv
ExistingInformation
Dwelling Type: Single Family '✓/ Two family Multi-family
Age of structure Basement type
Historic House Finished
Old King's Highway Unfinished
Number of Baths No. of Bedrooms
Total Room Count(not including baths) First Floor
Heat Type and Fuel Central Air Fireplaces
Garage: Detached Other Detached Structures: Pool
Attached Barn
None Sheds
Other
Builder Information
r
k i Telephone numberiD
Address License# Q
��Aa'(VA �Alka Home Improvement Contractor# 0 (t) 0 ��
Worker's Compensation # 1-4'�,c' -L�
NEW CONSTRUCTION OR ADDITIONS REQUIRE A SITE PLAN (AS BUILT) SHOWING EXISTING, AS WELL AS
PROPOSED STRUCTURES ON THE LOT.
ALL CON TRUCT N DEBRIS RESULTING FROM THIS PROJECT LL BE TAKEN TO—�7 � �� 191J
A z ems_
Project Cost ` t 'T
Fee I CIO
SIGNA DATE Z
BUILDING PERMIT DENIED FOR THE FOLLOWING REASON(S)
);z / BPERM T
7S FOR OFFICE USE ONLY
5/23/958 _
308. 155
ADDRESS 24 Potter Street VILLAGE Hyannis 3
D
avid Cronan
OWNER
DATE OF INSPECTION:
FOUNDATION
FRAME
INSULATION
FIREPLACE i +
ELECTRICAL: w
ROUGH FINAL
PLUMBING: ROUGH FINAL
GAS: t�JGH FINAL
-F -
FIN _ALB ,•,..
p .
DATE CLO
ASSOCIA NO. 11.
t_ t
71.
�✓G .
Restricted to: 00 '
DEPARTMENT OF PUBLIC SAFELY
L CONSTRUCTION SUPERVISOR LICENSE DO None
Number,k , Expires
•1G. 1 & 2 Family,Homes
i
keslriced To; 00
�. CHARLES C COOK -
'�10S ROCKY HILL RD
PLYMOUTH, MA 02360
??//�; p€ ��a � t �.4 Jf 4} 4��'£t t'�P ✓/IB�PM/vdW'+ P�✓/'�JtW[ UJfJ�dh
- ter•-.:� 1.iF.'p .,. e v f.. y ..
'mot • � ..',.,' , " r..-fY4,d ,.
HOKE�IMPROVEMENT CONTRACTOR}.
Registration'�100502 y +� '
° t TYPe` `+-PRIVATE:.CORPORAT ION rf',,
x Expiration �06/18/96 x,f`t
¢ i♦ f
.�ANERICAN.R OD N N11
u LI C
CharIN
les Cook : : ,+� ,.1 # ,'
G��o?•�Qo' ta6585.-NORTH STEMMONS #S102 4
t ,
�. t ADMINISTRATOR)
DALLAS TX 15247
's
Suggested Affidavit for Home Improvement Contractor Permit Application
For Office Use Only IAIkIF CITY/TqWILr
Permit No. l
Date
AFFIDAVIT
Home Improvement Contractor lAw
Supplement to Permit Application
MGLa 142A requires that the oreiconstroerion.nl erution rencwnlion• crnir mcxterniratinn mnvr-niort'nnrovement removal demolition.
or Construction or ion addition to any pre-cxisline OWner4)fetlflied bulldilU;M111411111IIY)11 I0851 01le 11"I llot More than four 4twellilU,unks....or
to olruclurrs which are bdlaccnl to such residence or building"Irc dune by registered twnlrafaurs,Willi ccrtain cxcxpliuus,alamg with other
rngyircmenta. \
Type of Work: �d '�� . 2 t l� Cosh
Address of Work r r
Owner Name:
Date of Permit Application: s —7 "T
I hereby certify that.
'Registration is not required for the following reason(s): .
_Work excluded by law
Job under $1,0W
Building not owner-occupied
_Owner pulling own permit
_Other (specify)
Notice is hereby given that:
OWNERS PULLING THEIR OWN PERMIT OR DEALING WITH UNREGISTERED
CONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK DO NOT HAVE
ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND UNDER MGL
c. 142A.
Signed under penalties of perjury:
I hereby apply for a permit as the agent of the owner:
V
Date Contractor ale Registration No.
OR:
Notwithstanding the above notice, I hereby apply for a permit as the owner of the above property:
Date Owner Name
..�=� OF Ik./T SACYUSETTS
` � = COMMONwL
M11VT OF IND
,�JJI'AIr: USTRIALACCIDENTS
! � . GOo WASHINGTON YnU E1 .
: Carsooec f
BOSTON, MASSACHUSE
fam es rl'S uilll , s
Co,- ,:ss,one, WOItI�IZS' COMPENSATION INSURANC.L AFFIDAVIT
(Gccns cc/perminee)
with a principal place of business/residence at;
4
(City/State/Z, )
do hereby,eeriify, under the:pains and penalties of perjury, chat: `
O 1 am an'employer.providing the following workers' compensation coverage for Myemployees working on this
job.
76? �
l :�-v LAI, GQ
G ,
Insurance Company Policy Number,
( J 1 am a sole propricror and have.no one working for me. ; l
( J 1 am a sole proprietor, generaJ contractor or homeowner (circle one) and have hired the eonuuctors'listed, below
who have the following workers' compensation insurance politics:
Name of Contractor Insurance Company/Policy Number
Name of Contractor Insurance Company/Policy.Nurnbcr
Namc of Contractor Insurance Company/Policy Number
Q 1 am a homeowner performing all the work myself. v
NOTE: Please be aware that while homeowners who employ persons to do maintenance,construction or repair work on a
dwelling of not more than three uniu.in which the bomeowner also resides or on the grounds appurtenant thereto are not generally
considered to be employers under the Workers' Compensation Act(CL C. 152,sect. 10)), application by a honscowner for a license
or permit may evidence the legal sutus of an employrr under,the %Vorkers' Compensation Act.
I understand that a copy ofrhit statement will be forwarded to thc'Department of Industrial Accidents' Office of Insurance for eovcraFc
vcnTiL cion and r;.at failure to wrcure coverage as required under Seedon 25A of MGL 152 can lead to the imposition of criminal penaldes
cunwsdot of a fine.of up to S1500.00 andlor imprisonment of up to one year and civil penalues in the form of a Stop Work Order and a
i,ne of S 100.00 a day against me.
this day of , 19
LICensrc/PcrR C. Licensor/Permtctor
-7 7 ��
In accordance with the provisions of MCL c 40, S 54, a condition of
Building Permit Number is that the debris resulting from
this work shall be disposed of in a properly licensed solid waste
disposal facility as defined by MCL c 111 , S 150A.
The debris will be disposed of in which City or Town _ te,
(fo � �c� - 5
TYPE OF CONTAINER
Poll
TRANSPORTATION
signature of rmit Applicant
Bate
l